Significance of intestinal metaplasia in different areas of esophagus including esophagogastric junction

Prevalence of Barrett's Esophagus and Esophageal Adenocarcinoma With and Without Gastroesophageal Reflux: A Systematic Review and Meta-analysis

BACKGROUND AND AIMS

Although gastroesophageal reflux disease (GERD) symptoms are an essential criterion for Barrett's esophagus (BE) screening in most gastroenterology society guidelines, a significant proportion of BE and esophageal adenocarcinoma (EAC) cases do not endorse them. In a systematic review and meta-analysis, we aimed to study the prevalence of BE/EAC in those with and without GERD.

METHODS

A systematic search was conducted through 5 major databases for studies reporting prevalence of BE/EAC in patients with and without GERD. Pooled proportions and odds ratios (ORs) of BE, long-segment BE, short-segment BE, dysplasia, and EAC in patients with and without GERD were synthesized.

RESULTS

Forty-three articles (12,883 patients with GERD; 51,350 patients without GERD) were included in the final analysis. BE prevalence was 7% (95% confidence interval [CI], 5.8%-8.5%) and 2.2% (95% CI, 1.6%-3%) among individuals with and without GERD, respectively. EAC prevalence was 0.6% (95% CI, 0.4%-1%) and 0.1% (95% CI, 0%-0.2%) in those with and without GERD, respectively. The overall risks for BE (OR, 2.91; 95% CI, 2.06-4.11) and long-segment BE (OR,4.17; 95% CI, 1.78-9.77) were higher in patients with GERD, but the risk for short-segment BE (OR, 1.77; 95% CI, 0.89-3.52) did not differ between the two groups. In 9 population-based high-quality studies (2244 patients with GERD; 3724 patients without GERD), BE prevalence in patients without GERD was 4.9% (95% CI, 2.6%-9%). BE prevalence was highest in North American studies (10.6% [GERD] and 4.8% [non-GERD]).

CONCLUSIONS

BE prevalence in those without GERD is substantial, particularly in large high-quality population-based studies. These data are important to factor in future BE/EAC early detection guidelines.

Endoscopic Surveillance of Intestinal Metaplasia of the Esophagogastric Junction: A Decision Modeling Analysis

INTRODUCTION

The incidence of esophagogastric junction adenocarcinoma (EGJAC) has been rising. Intestinal metaplasia of the esophagogastric junction (EGJIM) is a common finding in gastroesophageal reflux (irregular Z-line) and may represent an early step in the development of EGJAC in the West. Worldwide, EGJIM may represent progression along the Correa cascade triggered by Helicobacter pylori . We sought to evaluate the cost-effectiveness of endoscopic surveillance of EGJIM.

METHODS

We developed a decision analytic model to compare endoscopic surveillance strategies for 50-year-old patients after diagnosis of non-dysplastic EGJIM: (i) no surveillance (standard of care), (ii) endoscopy every 3 years, (iii) endoscopy every 5 years, or (iv) 1-time endoscopy at 3 years. We modeled 4 progression scenarios to reflect uncertainty: A (0.01% annual cancer incidence), B (0.05%), C (0.12%), and D (0.22%).

RESULTS

Cost-effectiveness of endoscopic surveillance depended on the progression rate of EGJIM to cancer. At the lowest progression rate (scenario A, 0.01%), no surveillance strategies were cost-effective. In moderate progression scenarios, 1-time surveillance at 3 years was cost-effective, at $30,989 and $16,526 per quality-adjusted life year for scenarios B (0.05%) and C (0.12%), respectively. For scenario D (0.22%), surveillance every 5 years was cost-effective at $77,695 per quality-adjusted life year.

DISCUSSION

Endoscopic surveillance is costly and can cause harm; however, low-intensity longitudinal surveillance (every 5 years) is cost-effective in populations with higher EGJAC incidence. No surveillance or 1-time endoscopic surveillance of patients with EGJIM was cost-effective in low-incidence populations. Future studies to better understand the natural history of EGJIM, identify risk factors of progression, and inform appropriate surveillance strategies are required.

Mechanisms and pathophysiology of Barrett oesophagus

Barrett oesophagus, in which a metaplastic columnar mucosa that can predispose individuals to cancer development lines a portion of the distal oesophagus, is the only known precursor of oesophageal adenocarcinoma, the incidence of which has increased profoundly over the past several decades. Most evidence suggests that Barrett oesophagus develops from progenitor cells at the oesophagogastric junction that proliferate and undergo epithelial-mesenchymal transition as part of a wound-healing process that replaces oesophageal squamous epithelium damaged by gastroesophageal reflux disease (GERD). GERD also seems to induce reprogramming of key transcription factors in the progenitor cells, resulting in the development of the specialized intestinal metaplasia that is characteristic of Barrett oesophagus, probably through an intermediate step of metaplasia to cardiac mucosa. Genome-wide association studies suggest that patients with GERD who develop Barrett oesophagus might have an inherited predisposition to oesophageal metaplasia and that there is a shared genetic susceptibility to Barrett oesophagus and to several of its risk factors (such as GERD, obesity and cigarette smoking). In this Review, we discuss the mechanisms, pathophysiology, genetic predisposition and cells of origin of Barrett oesophagus, and opine on the clinical implications and future research directions.

Effectiveness of esophagogastroduodenoscopy in changing treatment outcome in refractory gastro-esophageal reflux disease

BACKGROUND/AIMS

The effectiveness of screening esophagogastroduodenoscopy (EGD) for refractory gastroesophageal reflux disease (GERD) symptoms alone has not been validated.

METHODS

We performed an observational study of patients with refractory GERD who underwent EGD from 2013 to 2016 at a tertiary hospital. Among 928 patients with GERD, we excluded patients with other alarm features, other indications for EGD, history of gastroesophageal surgery, or EGD done for other diagnostic procedures, and identified 301 patients who underwent EGD solely for persistent reflux symptoms such as heartburn or regurgitation.

RESULTS

Among 301 patients with refractory GERD, 81.4% of patients were taking PPIs. 49.8% of patients had completely normal EGD findings and 33.6% of patients had benign or incidental findings. Two patients (0.6%) had LA grade C or D esophagitis, and 16.3% of patients had irregular Z line or salmon-colored mucosa. 91.0% (122/134) who had a biopsy had normal or benign findings. 4.0% (12/301) of patients had biopsy-proven intestinal metaplasia which is similar to the previously known prevalence of intestinal metaplasia in patients without heartburn (5.6%) and none had dysplasia or malignancy. Male sex was associated with endoscopic intestinal metaplasia suspected lesions in multivariate analysis (OR: 1.96, 95% CI: 1.04-3.70, p = .036) but not biopsy-proven intestinal metaplasia. Elderly age, obesity, alcohol or cigarette consumption, PPI use, GERD duration >3-5 years did not predict endoscopically suspected or biopsy-proven intestinal metaplasia. Only 5% of patients had a pH-impedance study for refractory reflux symptoms.

CONCLUSIONS

Most patients who underwent EGD for refractory GERD symptoms alone did not have pathological findings requiring a change in management. Screening EGD for patients only with persistent reflux symptoms should not be routinely recommended.

Stimulating peristalsis improves esophagogastric junction observation during sedated esophagogastroduodenoscopy in children and adolescents

Background and study aims

Sedation impairs full visualization of the esophagogastric junction (EGJ) and Z line (the squamocolumnar junction) during esophagogastroduodenoscopy (EGD). The aim of this study was to determine whether induction of esophageal peristalsis could improve the ability to evaluate the Z line in children and adolescents.

Patients and methods

Study 1: Consecutive patients (10-15 years) undergoing EGD with propofol or midazolam sedation were enrolled. The proportion of Z line observed was compared between the two groups. Study 2: The effect of an air infusion near the EGJ following deflation of the stomach to induce esophageal peristalsis was investigated in the patients (15-18 years), undergoing EGD with propofol sedation. The proportion of Z line observed was compared between the stimulated group and control group.

Results

Study 1: 149 patients were evaluated; 87 received propofol (43 boys; average age 13.2 years (range, 10-15)) and 62 received midazolam (30 boys; average age 12.8 years (range, 10-15)). The proportion of the Z line visualized was low but was greater with propofol vs. midazolam sedation (36.8% vs 16.1%, P=0.0059). Study 2: 102 patients were evaluated; 62 had induction of peristalsis (34 boys; average age 16.2 years (range, 15-18)) and 40 controls (20 boys; average age 16.8 years (range, 15-18)). Complete visualization of the Z line achieved in 95% (59 of 62) following induction of peristalsis vs. 37.5% (15 of 40) of controls (P>0.001).

Conclusions

Induction of esophageal peristalsis greatly improved visualization of the Z line during sedated EGD in children and adolescents.

African Americans with Barrett's esophagus are less likely to have dysplasia at biopsy

BACKGROUND

Barrett's Esophagus (BE) is a pre-malignant condition. Limited data on BE dysplasia prevalence exists among United States ethnic groups.

AIM

The purpose of this study was to determine if the frequency of BE with dysplasia varies among the major ethnic groups presenting to our institution.

METHODS

The University of Florida-Jacksonville endoscopy database was searched for all cases of endoscopic BE from September 2002 to August 2007. Histologic BE was diagnosed if salmon colored esophageal mucosa was endoscopically seen at least 1 cm above the top of the gastric folds and biopsy revealed intestinal metaplasia with Alcian blue-containing goblet cells. Demographic data collected for all included: age at diagnosis, ethnicity, sex, previous history of esophageal reflux, atypical manifestations (chronic cough, aspiration), endoscopic length of BE, presence or absence of hiatal hernia, esophageal stricture or ulcer, and presence or absence of dysplasia.

RESULTS

Salmon colored esophageal mucosa was observed in 405 of 7,308 patients (5.5%) and histologically confirmed in 115 of 405 patients (28%) reflecting an overall prevalence of BE of 115/7308 (1.6%) in this cohort. Ethnic distribution of histologic BE patients was as follows: 95 (83%) non-Hispanic white (nHw), 16 (14%) African American (AA) and 4 (3%) other. Long segment BE (LSBE) and any form of dysplasia was observed less frequently in AA than nHw (LSBE: 12% vs. 26% and dysplasia: 0% vs. 7%).

CONCLUSIONS

LSBE and dysplasia are less frequent in AA than nHw. Studies in AA with BE may illustrate factors limiting dysplasia and LSBE risk.

Meta-analyses of the effect of symptoms of gastroesophageal reflux on the risk of Barrett's esophagus

OBJECTIVES

Esophageal adenocarcinoma (EAC) is a devastating disease that has risen in incidence over the past several decades. Barrett's esophagus (BE) is an associated premalignant lesion. Current preventative efforts rely on endoscopic screening of individuals with gastroesophageal reflux disease (GERD) symptoms and surveillance endoscopy for those with BE. However, some recent studies have found a high prevalence of BE in patients without GERD, and others have found little or no association with GERD. We hypothesized that studies of higher-quality design show weaker associations of GERD with BE, and that GERD is only weakly associated with short-segment Barrett's esophagus (SSBE).

METHODS

We performed a systematic literature search in multiple online electronic databases regardless of language. Eligible studies required visualization of columnar mucosa and histological confirmation of intestinal metaplasia, and GERD symptoms ascertained by questionnaire or interview. The highest-quality sampling design was defined a priori by both cases and controls identified among unselected research volunteers ("research design") rather than by patients selected for endoscopy for clinical indications ("clinical design"), which introduces selection and ascertainment bias. A priori, heterogeneity was defined by Cochrane's Q P<0.20 and the inconsistency index (I(2); 25% low, 50% moderate, and 75% high). Heterogeneity of results can reflect significant differences in study design or effect modification by strata of outcomes.

RESULTS

Systematic review identified 13,392 citations. Evaluation identified 108 potentially relevant journal articles, of which 26 met eligibility. Of these, 14 studies identified cases of BE and controls based on clinical indication ("clinical design"), and 6 used the "research design." The remaining six studies identified cases of BE from patients undergoing endoscopy for clinical indication and controls among patients without known BE ("cases clinical/controls research"). The summary odds ratio (OR) for the association of GERD with BE from all studies was 2.90 (95% confidence interval (CI), 1.86-4.54), but the results were very heterogeneous (P=0.0001; I(2)=89%). When stratified by BE length and sampling design, the studies with clinical design showed substantial, but heterogeneous, associations with SSBE (OR, 2.38; 95% CI, 1.21-4.70; P=0.02; I(2)=62%), and stronger and homogeneous association with long-segment BE (LSBE; fixed effects OR, 2.96; 95% CI, 1.69-5.19; P=0.25; I(2)=25%). In the research study design, stratifying by length of BE resolved the heterogeneity and showed a strong association between GERD and LSBE (fixed effects OR, 4.92; 95% CI, 2.01-12.0; P=0.30; I(2)=19%) and no association with SSBE (fixed effects OR, 1.15; 95% CI, 0.763-1.73; P=0.84; I(2)=0%). Funnel plots showed potential evidence for bias against dissemination of small negative studies.

CONCLUSIONS

In the highest-quality studies, GERD symptoms are not associated with SSBE, but increased the odds of LSBE by fivefold. GERD symptoms can serve as a reliable predictor of LSBE, but not SSBE. If SSBE is considered worthy of identification, then current screening practices do not select patients at risk for endoscopy, and alternative methods of selection for screening need to be developed.

Predictors of specialized intestinal metaplasia in patients with an incidental irregular Z line

INTRODUCTION

Barrett's esophagus is a well-known complication of gastroesophageal reflux disease (GERD) and is associated with dysplasia and esophageal adenocarcinoma. Data on the prevalence of specialized intestinal metaplasia (SIM) in biopsy taken from an incidental irregular Z line are scarce.

AIM

To determine the prevalence of SIM in biopsies taken from an incidental irregular Z line in consecutive patients undergoing upper endoscopy.

METHODS

During the study period, we identified all adult patients who underwent an upper endoscopy with biopsies from an incidental finding of an irregular Z line. Demographic characteristics, prevalence of endoscopic findings, and major complaints were compared between those with SIM and those without.

RESULTS

A total of 166 out of 2000 (8.3%) consecutive patients were identified. Specialized intestinal metaplasia was found in 43.5% of all cases. Male sex and the presence of hiatus hernia were predictors of SIM (P=0.043 and 0.001, respectively), with relative risks of 2.02 (95% confidence interval: 1.01-4.0) and 3.31 (95% confidence interval: 1.66-6.58), respectively.

CONCLUSION

In this endoscopic and histological study, SIM was found to be a common finding in patients with irregular Z line. Male sex and the presence of diaphragmatic hernia were significantly associated with the presence of SIM.

Comparison of reflux esophagitis and its complications between African Americans and non-Hispanic whites

AIM: To determine the effect of ethnicity on the severity of reflux esophagitis (RE) and its complications.

METHODS: A retrospective search of the endoscopy database at the University of Florida Health Science Center/Jacksonville for all cases of reflux esophagitis and its complications from January 1 to March 31, 2001 was performed. Inclusion criteria were endoscopic evidence of esophagitis using the LA classification, reflux related complications and self-reported ethnicity. The data obtained included esophagitis grade, presence of a hiatal hernia, esophageal ulcer, stricture and Barrett’s esophagus, and endoscopy indication.

RESULTS: The search identified 259 patients with RE or its complications, of which 171 were non-Hispanic whites and 88 were African Americans. The mean ages and male/female ratios were similar in the two groups. RE grade, esophageal ulcer, stricture and hiatal hernia frequency were likewise similar in the groups. Barrett’s esophagus was present more often in non-Hispanic whites than in African Americans (15.8% vs 4.5%; P < 0.01). Heartburn was a more frequent indication for endoscopy in non-Hispanic whites with erosive esophagitis than in African Americans (28.1% vs 7.9%; P < 0.001).

CONCLUSION: Distribution of RE grade and frequency of reflux-related esophageal ulcer, stricture and hiatal hernia are similar in non-Hispanic whites and African Americans. Heartburn was more frequently and nausea/vomiting less frequently reported as the primary endoscopic indication in non-Hispanic whites compared with African Americans with erosive esophagitis or its complications. African Americans have a decreased prevalence of Barrett’s esophagus compared with non-Hispanic whites.

Prevalence of Barrett's esophagus in individuals without typical symptoms of gastroesophageal reflux disease

BACKGROUND: Barrett’s esophagus, the major risk factor for esophageal adenocarcinoma, is detected in approximately 10%-14% of individuals submitted to upper endoscopy for the assessment of gastroesophageal reflux disease related symptoms. Prevalence studies of Barrett’s esophagus in individuals without typical symptoms of gastroesophageal reflux disease have reported rates ranging from 0.6% to 25%. AIM: To determine the prevalence of Barrett’s in a Brazilian population older than 50 years without typical symptoms of gastroesophageal reflux disease. METHODS: A total of 104 patients (51 men), mean age of 65 years, with an indication for upper endoscopy but without symptoms of heartburn and/or acid regurgitation (determined with a validated questionnaire) were recruited. Subjects submitted to upper endoscopic examination in the last 10 years or using antisecretory medication (proton pump inhibitors) during the last 6 months were not included. Methylene blue chromoscopy was performed during the endoscopic exam to facilitate identification of the metaplastic epithelium. RESULTS: Barrett’s esophagus was diagnosed endoscopically and confirmed by histology in four patients, all of them males. The metaplastic segment was short (less than 3 cm) and free of dysplasia in all patients. The prevalence of Barrett’s esophagus was 7.75% in the male population and 3.8% in the general population studied. CONCLUSION: Due to the low prevalence of Barrett’s esophagus found in the present study, associated with the finding of short-segment Barrett’s esophagus in all cases diagnosed and the absence of dysplasia in the material analyzed, endoscopic screening for Barrett’s esophagus in patients above the age of 50 without the classical symptoms of gastroesophageal reflux disease is not indicated for the Brazilian population.

Normalization of intestinal metaplasia in the esophagus and esophagogastric junction: incidence and clinical data

BACKGROUND

Attention has focused on whether normalization, regression, and development of dysplasia and cancer in specialized intestinal metaplasia (SIM) differ among long-segment Barrett's esophagus (LSBE), short-segment BE (SSBE), and esophagogastric junction SIM (EGJSIM). We prospectively followed a cohort of SIM patients receiving long-term antisecretory medications to determine: (a) histologic normalization (no evidence of SIM on biopsy), (b) change in SIM length, (c) incidence of dysplasia and cancer, and (d) factors associated with normalization.

METHODS

One hundred forty-eight patients with SIM were identified in our original cohort. Of these, 60.5% (23/38) LSBE, 69.8% (44/63) SSBE, and 72.3% (34/47) EGJSIM patients underwent repeat surveillance over a mean 44.4 +/- 9.7 months. Demographic, clinical, and endoscopic data were obtained.

RESULTS

(a) With long-term, antisecretory therapy, normalization occurred in 0/23 LSBE, 30% (13/44) of SSBE, and 68% (23/34) of EGJSIM (P < 0.001). (b) Normalization was more likely with EGJSIM (odds ratio [OR] 6.7, CI 2.3-19.3, P= 0.005), female gender (OR 7.3, CI 2.3-23.1, P= 0.001), or absence of hiatal hernia (OR 2.9, CI 1.02-8.06, P= 0.002). (c) A significant decrease in mean SIM length was noted for the entire population (2.5 +/- 0.3 to 2.13 +/- 0.3 cm, P= 0.004). (d) Follow-up incidence of dysplasia and cancer was 26.1% (3 indefinite, 2 low-grade dysplasia [LGD], 1 cancer) for LSBE, 6.8% (2 indefinite, 1 LGD) for SSBE, and none for EGJSIM (P < 0.004).

CONCLUSIONS

(a) Normalization of SIM occurs most frequently in EGJSIM>SSBE>LSBE. (b) Factors associated with normalization favor less severe GER and shorter segments of SIM. (c) Surveillance of LSBE results in the greatest yield for identifying dysplasia and cancer.

Short segment Barrett's esophagus and distal gastric intestinal metaplasia

BACKGROUND

Short segment Barrett's esophagus is defined by the presence of <3 cm of columnar-appearing mucosa in the distal esophagus with intestinal metaplasia on histophatological examination. Barrett's esophagus is a risk factor to develop adenocarcinoma of the esophagus. While Barrett's esophagus develops as a result of chronic gastroesophageal reflux disease, intestinal metaplasia in the gastric cardia is a consequence of chronic Helicobacter pylori infection and is associated with distal gastric intestinal metaplasia. It can be difficult to determine whether short-segment columnar epithelium with intestinal metaplasia are lining the esophagus (a condition called short segment Barrett's esophagus) or the proximal stomach (a condition called intestinal metaplasia of the gastric cardia).

AIMS

To study the association of short segment Barrett's esophagus (length <3 cm) with gastric intestinal metaplasia (antrum or body) and infection by H. pylori.

PATIENTS AND METHODS

Eight-nine patients with short segment columnar-appearing mucosa in the esophagus, length <3 cm, were studied. Symptoms of gastroesophageal reflux disease were recorded. Biopsies were obtained immediately below the squamous-columnar lining, from gastric antrum and gastric corpus for investigation of intestinal metaplasia and H. pylori.

RESULTS

Forty-two from 89 (47.2%) patients were diagnosed with esophageal intestinal metaplasia by histopathology. The mean-age was significantly higher in the group with esophageal intestinal metaplasia. The two groups were similar in terms of gender (male: female), gastroesophageal reflux disease symptoms and H. pylori infection. Gastric intestinal metaplasia (antrum or body) was diagnosed in 21 from 42 (50.0%) patients in the group with esophageal intestinal metaplasia and 7 from 47 (14.9%) patients in the group with esophageal columnar appearing mucosa but without intestinal metaplasia.

CONCLUSION

Intestinal metaplasia is a frequent finding in patients with <3 cm of columnar-appearing mucosa in the distal esophagus. In the present study, short segment intestinal metaplasia in the esophagus is associated with distal gastric intestinal metaplasia. Gastroesophageal reflux disease symptoms and H. pylori infection did not differ among the two groups studied.

Surgical management of esophagogastric junction tumors

Surgical resection with lymphadenectomy is the mainstay of treatment for all resectable esophagogastric junction tumors, prior to systemic generalization of the disease. This makes accurate pre-treatment staging and classification of the tumors most demanding. A well-established and internationally accepted classification for adenocarcinomas of the esophagogastric junction (AEG) helps to choose the appropriate surgical approach and to make results from different institutions comparable. Distal esophageal adenocarcinomas (AEGI) are distinguished from true cardia carcinomas (AEG II) and subcardiac gastric cancers (AEG III). Substantial advancements in this surgical field during the preceding decades have clearly revealed that individualization of the surgical strategy is the key to successfully approaching these entities. In this review we discuss the surgical management of esophagogastric junction tumors with a tailored surgical strategy.

Epidemiology and molecular biology of Barrett esophagus

Over the past three decades, there has been a marked change in the epidemiology of esophageal malignancy, with an increasing incidence of esophageal adenocarcinoma. The reasons for this are largely unknown and remain controversial, but several lifestyle risk factors have been proposed, including gastroesophageal reflux disease (GERD). It is hypothesized that chronic GERD results in acute mucosal injury, promotes cellular proliferation, and induces specialized columnar metaplasia (Barrett esophagus). Progression of Barrett esophagus to invasive adenocarcinoma is reflected histologically by the metaplasia-dysplasia-carcinoma sequence. Dysplasia is widely regarded as the precursor of invasive cancer, and high-grade dysplasia in Barrett epithelium is frequently associated with esophageal adenocarcinoma. Although several molecular alterations have been described in Barrett esophagus, it is anticipated that relatively few will prove to be clinically useful. To date, biomarkers which currently appear to predict the progression of Barrett esophagus to invasive malignancy include aneuploidy, loss of heterozygosity of 17p (implicating the p53 tumor suppressor gene), and cyclin D1 protein overexpression, and with further validation, will most likely be incorporated into routine clinical practice. It is anticipated that models incorporating objective scores of sociodemographic and lifestyle risk factors (ie, age, gender, body mass index), severity of reflux symptoms, endoscopic and histologic findings, and an assessment of a panel of biomarkers will be developed to further define subsets of patients with Barrett esophagus at increased risk for malignant progression, thereby permitting the development of more rational endoscopic surveillance and screening programs.

Diagnostic accuracy of magnifying chromoendoscopy with detection of intestinal metaplasia and dysplasia using acetic acid in Barrett's esophagus

OBJECTIVES

Endoscopy with systematic randomized biopsies aims to improve the detection of intestinal metaplasia (IM) and dysplasia in Barrett's esophagus (BE). Magnifying chromoendoscopy with alcoholic acetic acid might allow directed biopsies to improve detection of IM and dysplasia.

PATIENTS AND METHODS

Twenty-eight patients were studied with magnifying chromoendoscopy (Optical power zoom x 115, alcoholic acetic acid). Endoscopy biopsies were performed on one or several zones of BE chosen randomly, for which the chromoendoscopic pattern was determined according to Guelrud's classification.

RESULTS

Among seventy-two biopsies, the agreement between magnifying chromoendoscopy and histology and the positive predictive value of the association of patterns III and IV for the diagnosis of IM were 72.4%; sensibility and specificity were respectively 95.5% and 42.9%. The diagnostic accuracy was 75%. Among the six biopsies that showed high-grade dysplasia, three were suspected because of two particular patterns: local loss of ridged cerebriform pattern due to the disorganization of the mucosal folds and hypervascularization of the mucosa.

CONCLUSION

Magnifying chromoendoscopy with acetic acid allows targeted biopsies of the IM in BE and may help to detect high-grade dysplasia.

Advanced imaging and technology in gastrointestinal neoplasia: summary of the AGA-NCI Symposium October 4-5, 2004

Imaging and other advanced technologies for detection of gastrointestinal cancers are undergoing a major revolution on several fronts. This is facilitated by convergence of key technologies including advanced endoscopic-detection systems, more specific contrast agents, rapid and high-resolution cross-sectional imaging, and miniaturization of construction systems for making all imaging equipment smaller and less invasive. This convergence is occurring along traditional translational research pathways (clinical medicine-molecular biology) as well as nontraditional lines (clinical medicine-optical physics/engineering and molecular biology-optical physics/engineering). These new efforts are producing a wide array of technologies aimed at improving detection, classification, and monitoring of gastrointestinal neoplasia, especially for colorectal and esophageal cancer because of easier accessibility. A critical goal is to detect lesions at their premalignant stages, thereby permitting meaningful intervention. Inspired by these advances, the American Gastroenterological Association and the National Cancer Institute sponsored a symposium held in Bethesda, MD, from October 4-5, 2004, bringing together leading investigators with diverse backgrounds in imaging technology. The aims of this symposium were to summarize the state of the art and priorities for research in the coming decade in the field of imaging and advanced technology for gastrointestinal neoplasia. In this overview, we summarize the salient results of that symposium. The initial sections discuss the major technologies in each area of endoluminal imaging and molecular imaging followed by applications to specific diseases such as Barrett's esophagus and colon neoplasia. Each section focuses on the current state of the art then lists major priorities for research in the field.

Is cytokeratin immunoreactivity useful in the diagnosis of short-segment Barrett's oesophagus in Korea?

BACKGROUND

Cytokeratin 7/20 staining has been reported to be helpful in diagnosing Barrett's oesophagus and gastric intestinal metaplasia. However, this is still a matter of some controversy.

OBJECTIVE

To determine the diagnostic usefulness of cytokeratin 7/20 immunostaining for short-segment Barrett's oesophagus in Korea.

METHODS

In patients with Barrett's oesophagus, diagnosed endoscopically, at least two biopsy specimens were taken from just below the squamocolumnar junction. If goblet cells were found histologically with alcian blue staining, cytokeratin 7/20 immunohistochemical stains were performed. Intestinal metaplasia at the cardia was diagnosed whenever biopsy specimens taken from within 2 cm below the oesophagogastric junction revealed intestinal metaplasia. Barrett's cytokeratin 7/20 pattern was defined as cytokeratin 20 positivity in only the superficial gland, combined with cytokeratin 7 positivity in both the superficial and deep glands.

RESULTS

Barrett's cytokeratin 7/20 pattern was observed in 28 out of 36 cases (77.8%) with short-segment Barrett's oesophagus, 11 out of 28 cases (39.3%) with intestinal metaplasia at the cardia, and nine out of 61 cases (14.8%) with gastric intestinal metaplasia. The sensitivity and specificity of Barrett's cytokeratin 7/20 pattern were 77.8 and 77.5%, respectively.

CONCLUSION

Barrett's cytokeratin 7/20 pattern can be a useful marker for the diagnosis of short-segment Barrett's oesophagus, although the false positive or false negative rate is approximately 25%.

New Molecular Concepts of Barrett’s Esophagus: Clinical Implications and Biomarkers

Barrett's esophagus (BE) represents the most serious histological consequence of gastroesophageal reflux disease (GERD) that develops in 5-10% of patients with GERD. Given that BE is the only known precursor to esophageal adenocarcinoma (EA), a systematic endoscopic biopsy protocol can detect EAs at an early stage. However, endoscopic and histopathological evaluation of BE are not adequate for effective screening of high risk patients. Therefore, molecular abnormalities associated with BE have been considered as surrogate markers and their use as such is proposed. Flow cytometry is the most useful adjunct to histology, and ploidy status of BE is an independent risk factor. Cyclin D1 overexpression is inversely correlated with survival in EA. C-erbB2 (+) patients have poorer prognosis. High plasma adenomatous polyposis coli levels correlate with reduced patient survival. p53 expression allows patient risk for EA stratification. Nuclear factor-kappaB overexpression inversely correlates with good response to adjuvant chemotherapy and radiotherapy in EA. Patients with cyclooxygenase-2 overexpression have reduced survival rates. Increased E-cadherin staining is associated with shorter survival in EA patients who received chemoradiotherapy. Finally, existing data cannot rule out a correlation between EA and colorectal tumors. Seventeen BE molecular alterations yielded noteworthy clinical implications. Apart from endoscopy and histology, these data allow for better risk stratification for patients with BE and for more efficient and timely therapeutic approaches.

The frequency of Barrett's esophagus in high-risk patients with chronic GERD

BACKGROUND

The reported frequency of Barrett's esophagus (BE) in patients with reflux symptoms varies from 5% to 15%. The exact frequency of long-segment BE (LSBE) (>3 cm) and short-segment BE (SSBE) (<3 cm) in patients with chronic symptoms of GERD is uncertain. The aim of this study was to determine the frequency of LSBE and SSBE in consecutive patients presenting for a first endoscopic evaluation with GERD as the indication.

METHODS

Consecutive patients presenting to the endoscopy unit of a Veterans Affairs Medical Center for a first upper endoscopy with the indication of GERD were prospectively evaluated. Demographic information (gender, race, age), data on tobacco use and family history of esophageal disease, and body mass index (BMI) were recorded for all patients. Before endoscopy, all patients completed a validated GERD questionnaire. The diagnosis of BE was based on the presence of columnar-appearing mucosa in the distal esophagus, with confirmation by demonstration of intestinal metaplasia in biopsy specimens. All patients with erosive esophagitis on the initial endoscopy underwent a second endoscopy to document healing and to rule-out underlying BE. Patients with a history of BE, alarm symptoms (dysphagia, weight loss, anemia, evidence of GI bleeding), or prior endoscopy were excluded.

RESULTS

A total of 378 consecutive patients with GERD (94% men, 86% white; median age 56 years, range 27-93 years) were evaluated. A diagnosis of BE was made in 50 patients (13.2%). The median length of Barrett's esophagus (BE) was 1.0 cm (range 0.5-15.0 cm). Of the patients with BE, 64% had short-segment BE (SSBE) (overall SSBE frequency 8.5%). The overall frequency of long-segment BE (LSBE) was 4.8%. A hiatal hernia was detected in 62% of the patients with BE. Of the 50 patients with BE (median age 62 years, range 29-81 years), 47 (94%) were men and 98% were white. Eighteen patients (36%) were using tobacco at the time of endoscopy; 23 (46%) were former users. The median body mass index (BMI) of patients with BE was 27.3 (overweight). There were no significant differences between patients with LSBE and SSBE with respect to age, gender, ethnicity, BMI, and GERD symptom duration.

CONCLUSIONS

The frequency of BE in a high-risk patient group (chronic GERD, majority white men, age > 50 years) who sought medical attention is 13.2%, with the majority (64%) having SSBE. These data suggest that the frequency of BE in patients with GERD has not changed. The true prevalence of BE in the general population, including those who do not seek care, is undoubtedly lower, currently and historically. The majority of patients with BE are overweight and have a hiatal hernia. Demographic data for patients with LSBE and SSBE are similar, indicating that these are a continuum of the same process.

Barrett esophagus: update for radiologists

Barrett esophagus is a well-recognized entity in which there is progressive columnar metaplasia of the lower esophagus due to longstanding gastroesophageal reflux and reflux esophagitis [1]. This condition is important because it is associated with an increased risk of developing esophageal adenocarcinoma by a well-established sequence from dysplasia to carcinoma [2]. During the past decade, however, an explosion of new data has dramatically affected our understanding of Barrett esophagus. Not only have revised histopathologic criteria been developed for this condition, but it is currently believed that patients with Barrett esophagus should be classified as having "short-segment" or "long-segment" disease based on the extent of columnar metaplasia in the distal esophagus. This distinction has important implications for the risk of developing esophageal adenocarcinoma and subsequent need for endoscopic surveillance. The purpose of this article is to present these new concepts about Barrett esophagus and provide radiologists with a more current framework for diagnosing this condition.

Detection of cardia intestinal metaplasia: do the biopsy number and location matter?

BACKGROUND AND AIM

Presence of intestinal metaplasia in the gastric cardia (cardia intestinal metaplasia, CIM) has been reported in 5-34% of patients undergoing upper endoscopy and is a topic of interest given the rising incidence of cancer in this location. The aim of this article is to determine the prevalence of CIM in biopsies obtained from two separate locations within the gastric cardia.

METHODS

Patients presenting to the endoscopy unit for upper endoscopy for any symptoms were invited to participate in the study. The biopsy protocol included: eight biopsies from the gastric cardia, four from upper cardia (forceps across the squamocolumnar junction), four from lower cardia (within 1 cm of upper cardia), and four each from the gastric body and antrum. All cardia biopsies were stained with hematoxylin and eosin (H&E) and alcian blue at pH 2.5 for the presence of goblet cells and the body/antrum biopsies were stained with Steiner silver stain for Helicobacter pylori detection. In patients testing negative for H. pylori by histology, a serology test was performed.

RESULTS

Sixty-five patients have been evaluated by this protocol; median age 54 yr (range: 34-81 yr), 63 males, 53 Caucasians, and 12 African Americans. The detection of CIM was as follows: upper cardia only, 7, both upper and lower cardia, 5, and lower cardia only, 7. Thus, CIM was detected in 12 patients (18%) in the upper cardia biopsies, in 12 patients (18%) in the lower cardia; overall prevalence of CIM was 29% (19 patients). Fifty-eight percent of CIM patients tested positive for H. pylori by either histology or serology. The addition of serology allowed for the detection of eight additional H. pylori-positive CIM patients.

CONCLUSIONS

The prevalence of CIM in this study was similar (18%, four biopsies) at each location; however, if both locations were considered (eight biopsies), the prevalence increased to 29%. Thus, CIM prevalence may vary depending on the number of biopsies obtained as well as on the location of biopsies. Use of additional testing detects more patients who are H. pylori positive and should be performed if association of CIM with H. pylori is contemplated. Future endoscopic studies of the gastric cardia should specify the location of biopsies, the number of biopsies obtained, and the tests used to diagnose H. pylori.

Review article: prevalence of Barrett's oesophagus and metaplasia at the gastro-oesophageal junction

Barrett's oesophagus, a complication of chronic gastro-oesophageal reflux disease, is the premalignant lesion for oesophageal and gastro-oesophageal junction adenocarcinoma. Described in the 1950s by Norman Barrett, the diagnostic criterion for this lesion has evolved significantly over the last three decades. Endoscopic Barrett's oesophagus requires the recognition of columnar mucosa in the distal oesophagus; documentation of metaplastic tissue is confirmed by random biopsies. Given this changing definition of Barrett's metaplasia, the prevalence rates vary in the literature depending on the diagnostic criteria applied. However, it is generally accepted that approximately 10% of patients with chronic gastro-oesophageal reflux disease will be diagnosed with this condition. There are no population-based studies on the prevalence of Barrett's oesophagus, but emerging data indicate that it may be equally prevalent in asymptomatic individuals. These studies require confirmation. Although the incidence of oesophageal adenocarcinoma is increasing rapidly, it is unclear whether the true incidence of Barrett's oesophagus is increasing at the same time. On the other hand, metaplasia at the gastro-oesophageal junction appears to be distinct from Barrett's oesophagus, is probably not related to chronic gastro-oesophageal reflux disease and is a common finding if routine biopsies are obtained at the gastro-oesophageal junction. This article reviews our current understanding of the diagnosis, definition and prevalence of both of these lesions.

Enhanced magnification endoscopy in the upper gastrointestinal tract

In diseases such as Barrett's esophagus and celiac disease, the mucosal abnormality is patchy or irregular, highlighting the need for targeted biopsies. Enhanced magnification endoscopy is an effective, readily available method that can be used to assist in target biopsies and endoscopic diagnosis leading to an endoscopic classification system. The technique is not difficult and adds only an additional 5 to 10 minutes to a standard endoscopic procedure;however, most endoscopists never receive instruction in magnification endoscopy during their training. The value of this technique is still being explored, but the improvement in diagnostic accuracy will have an impact on decreasing morbidity and mortality without a large increase in cost. Increased use of this technique will aid in the diagnosis of celiac disease and simplify the classification system for Barrett's esophagus. Using enhanced magnification endoscopy at multiple centers in studies will help to determine the intra- and inter-observer variability, define the endoscopic criteria for dysplasia and early neoplastic changes, and standardize the visualized mucosal patterns more clearly.

Metaplasia intestinal especializada de esôfago distal na doença do refluxo gastroesofágico: prevalência e aspectos clínico-epidemiológicos

RACIONAL: A metaplasia intestinal especializada pode ser classificada, de acordo com os achados endoscópicos e histológicos, em Barrett longo, Barrett curto e metaplasia intestinal da cárdia. O esôfago de Barrett é doença adquirida que ocorre em aproximadamente 10% a 13% dos indivíduos com doença do refluxo gastroesofágico e representa uma condição pré-neoplásica. É caracterizado por substituição do epitélio escamoso estratificado pelo metaplásico colunar especializado, contendo células caliciformes. OBJETIVOS: Determinar, prospectivamente, a prevalência e as características clínico-epidemiológicas da metaplasia intestinal especializada de esôfago distal na doença do refluxo gastroesofágico. MÉTODOS: Entre abril e outubro de 2002, 402 pacientes com sintomas da doença do refluxo gastroesofágico foram avaliados através de questionário padronizado que abordava as variáveis demográficas e foram submetidos a exame endoscópico com biopsias 1 cm abaixo da junção escamocolunar, nos quatro quadrantes. RESULTADOS: Metaplasia intestinal especializada foi encontrada em 18,4% dos pacientes: 0,5% Barrett longo, 3,2% Barrett curto e 14,7% metaplasia intestinal da cárdia. Houve tendência de maior número de homens apresentando esôfago de Barrett e mulheres com metaplasia intestinal da cárdia. Todos com esôfago de Barrett eram da raça branca. Não houve relação entre a intensidade dos sintomas da doença do refluxo gastroesofágico e a presença de metaplasia intestinal especializada. O tempo de duração de sintomas superior a 5 anos foi uma tendência nos portadores de esôfago de Barrett. Este grupo também apresentou mais hérnia de hiato e esofagite mais intensa do que aqueles com metaplasia intestinal da cárdia. Não houve relação entre uso de tabaco ou álcool e metaplasia intestinal especializada. CONCLUSÕES: Esôfago de Barrett foi mais relacionado ao sexo masculino, com sintomas de longa cronicidade, esofagite mais intensa e sem associação com tabaco ou álcool.

Trends in incidence and prevalence of specialized intestinal metaplasia, barrett's esophagus, and adenocarcinoma of the gastroesophageal junction

Most available information on the epidemiology of Barrettacute;s esophagus (BE) relates to patients with long segments (> 3 cm) of specialized intestinal metaplasia (SIM). Its prevalence is 3% in patients undergoing endoscopy for reflux symptoms and 1% in those undergoing endoscopy for any clinical indication. The latter prevalence is similar to the 1% found in autopsy series. A "silent majority" with BE remain unrecognized in the general population. BE is more common in men, and the prevalence rises with age. Recent endoscopic series document a rise in the diagnosis of endoscopically apparent short segments (< 3 cm) of BE (SSBE). The prevalence of SSBE in both unselected and reflux patients is 8% to 12%. Specialized intestinal metaplasia at the cardia, below a normal-appearing squamocolumnar junction, has been reported to vary from 6% to 25% in patients presenting for upper endoscopy. Unlike patients with long segment Barrett's esophagus (LSBE), the role of gastroesophageal reflux disease in the pathogenesis of SSBE and SIM of the cardia is controversial. Recent data suggest that the etiology of SIM of the cardia might be secondary to Helicobacter pylori infection, although the role of other environmental factors cannot be ruled out. The incidence of adenocarcinoma of the esophagus and esophagogastric juction (EGJ) has been increasing over the past 15 years in Western countries. Surgical series and population-based studies show that by 1994 adenocarcinomas of the esophagus accounted for half of all esophageal cancer among white men. LSBE and SSBE predispose to the development of adenocarcinoma of the esophagus and EGJ. The role of SIM of the cardia as a precursor lesion for EGJ adenocarcinoma is still unclear. The prevalences of dysplasia in LSBE and SSBE are around 6% and 8%, respectively. The incidence of adenocarcinoma in patients with LSBE is about 1 in 100 patient-years. Cancer risk for SSBE and SIM at the cardia is unknown. Smoking and obesity increase the risk for esophageal and EGJ adenocarcinomas.

Role of surveillance in intestinal metaplasia of the esophagus and gastroesophageal junction

This article reviews current concepts of cancer surveillance in esophageal columnar metaplasia (Barrett's esophagus) and intestinal metaplasia at the gastroesophageal junction. An overview is given of the available data on the prevalence of intestinal metaplasia in biopsies from the distal esophagus and from the gastroesophageal junction. Furthermore, special attention is given to the endoscopic detection of dysplasia and early malignancy. Finally, the costs of endoscopic surveillance and its effect on mortality rates from esophageal adenocarcinoma are discussed.

Accuracy of magnifying endoscopy with methylene blue in the diagnosis of specialized intestinal metaplasia and short-segment Barrett's esophagus in Japanese patients without Helicobacter pylori infection

BACKGROUND

The use of methylene blue chromoendoscopy in the diagnosis of specialized intestinal metaplasia in short-segment Barrett's esophagus is controversial. This study evaluated the use of magnifying endoscopy with methylene blue for this purpose.

METHODS

A total of 30 patients (21 men, 9 women; median age 61 years, range 32-79 years) with short lengths of columnar-lined esophagus were enrolled in a prospective trial of magnifying endoscopy with methylene blue in which the appearance after methylene blue staining was used to target biopsy specimens. Patients were screened for Helicobacter pylori infection, and only those without infection were enrolled (because many Japanese patients have pan-gastritis caused by H pylori infection, and intestinal metaplasia distal to the squamocolumnar junction may be secondary to H pylori-induced gastritis). All biopsy specimens were stained with H and E; MUC2 immunostaining was used to identify specialized intestinal metaplasia.

RESULTS

Thirty patients with short-segment columnar-lined esophagus underwent magnifying endoscopy with methylene blue. Ninety-three biopsy specimens were obtained, 33 from methylene blue-stained areas and 60 from unstained areas, each about 7 mm from the marginal edge of stained areas. Specialized intestinal metaplasia was confirmed in biopsy specimens from 28 of the 33 stained areas (sensitivity 84.8%); in biopsy specimens from 55 of the 60 unstained areas, specialized intestinal metaplasia was not found (specificity 91.7%). In magnified views of methylene blue-positive areas, a tubular, cavernous, or elliptical pattern was seen. Sixteen of 21 men (76.2%) and 3 of 9 women had specialized intestinal metaplasia, and short-segment Barrett's esophagus was diagnosed in these patients. Even in patients with less than 1 cm of columnar-lined esophagus, 8 of 10 stained areas contained specialized intestinal metaplasia (sensitivity 80%) and 23 of 24 unstained areas did not (specificity 95.8%). Six of 12 patients (50%) with less than 1 cm of columnar-lined esophagus had specialized intestinal metaplasia. In total, 19 of 30 patients had specialized intestinal metaplasia.

CONCLUSIONS

Magnifying endoscopy with methylene blue selectively detects specialized intestinal metaplasia within short-segment columnar-lined esophagus.

Effect of Helicobacter pylori infection in Barrett's esophagus and the genesis of esophageal adenocarcinoma

The relation between Helicobacter pylori and gastroesophageal reflux disease is unclear. Recent reports have suggested a possible protective role for H. pylori, particularly in preventing the complications of gastroesophageal reflux disease (GERD). The purpose of this article is to present a brief overview of the recent literature regarding the role of H. pylori in the genesis of the complications of GERD, focusing on Barrett's esophagus and esophageal adenocarcinoma. The prevalence of H. pylori infection in the population of the West is around 40% and is not different in cohorts of patients with GERD. When the infection induces pangastritis or corpus-predominant gastritis, there may be concomitant reduced gastric acid secretion. Eradication of the bacteria in this subgroup of patients may enhance gastric acid secretion and provoke reflux symptoms. H. pylori organisms do not colonize the specialized intestinal metaplasia characteristic of Barrett's esophagus. H. pylori infection rates in gastric mucosa of patients with Barrett's esophagus occur at a similar or slightly lower frequency than is found in controls. Gastric infection with cagA-positive strains of H. pylori appears to be uncommon in patients with Barrett's esophagus. Furthermore, epidemiologic studies indicate that cagA-positive strains are protective against esophageal adenocarcinoma. Several investigators have proposed that the decreasing prevalence of H. pylori infection might be an important factor in the rising incidence of this tumor.

Histology of Barrett's esophagus and dysplasia

This article explores issues related to the diagnosis of Barrett's esophagus (BE) in endoscopic biopsies and dysplasia in Barrett's epithelium. The definitions of BE, including long- and short-segment BE, are reviewed, with an emphasis on the significance of intestinal metaplasia (IM). IM of the gastroesophageal junction and cardia is reviewed and problems in its distinction from short-segment BE are discussed. In addition, the article reviews the classification of dysplasia in Barrett's mucosa, with reference to problematic areas, such as sampling error and interobserver variability. Biomarkers and their role in the diagnosis of dysplasia and stratification of risk are summarized.

Lower esophagus in dyspeptic Iranian patients: a prospective study

BACKGROUND

Gastroesophageal junction cancer has increased over time in Western countries. Gastroesophageal reflux disease (GERD) is considered to be a major risk factor. We prospectively studied the prevalence of clinical, histological and endoscopic GERD, and premalignant changes among dyspeptic Iranian patients referred for upper gastrointestinal endoscopy (UGIE).

METHODS

Consenting patients referred for UGIE to our clinic were enrolled. Their symptoms were recorded, UGIE was conducted, and biopsies from all suspicious lesions and across the Z-line were taken.

RESULTS

Of the 344 enrolled patients, 269 (135 women, 134 men; mean age: 41.6 years) were evaluated. One major GERD symptom (heart burn, acid regurgitation, dysphagia and chest pain) was seen in 209 (77.6%) patients, and 207 patients (76.1%) had endoscopic esophagitis. Thirteen patients (5%) had specialized intestinal metaplasia at the gastrointestinal junction (SIM-GEJ), and three had glandular dysplasia (two low-grade, one high-grade). No symptom could predict the presence of histological or endoscopic findings. Patients with dysplasia had more advanced degrees of endoscopic esophagitis.

CONCLUSION

Gastroesophageal reflux disease is common among Iranian patients referred for diagnostic endoscopy. The prevalence of SIM-GEJ among this population was comparable to that reported in Western countries.

Impact of imprint cytology in detecting short segment Barrett's esophagus

BACKGROUND

Short-segment Barrett's esophagus (SSBE) is defined by the presence of columnar-appearing mucosa in distal esophagus (involving less than 2 to 3 cm), with intestinal metaplasia on biopsy. Its potential to develop dysplasia and cancer may require a surveillance program with better diagnostic tools to detect intestinal metaplasia.

GOALS

To investigate the role of imprint cytology as a diagnostic tool either alone or combined with histology in SSBE.

STUDY

Seventy-nine patients (46 men, 33 women) with SSBE diagnosed during elective upper gastroscopy were included. Patients with serrated z-line with short tongues of pink mucosa and patients with a circular non-serrated z-line that extended less than 2 cm above the esophagogastric junction were biopsied on four quadrants just distal to z-line. Four slides of imprint preparation (including 1, 2, 3, and 4 touching of each biopsy specimen) was made for cytologic examination. Hematoxylin and eosin and Alcian blue staining for histologic examinations and Alcian Blue for cytologic evaluations were used to find evidence of intestinal metaplasia.

RESULTS

Intestinal metaplasia was detected in 15 (19%), 21 (27%), and 30 (38%) patients by histologic examination with hematoxylin and eosin alone, by Alcian blue alone, and by histologic plus cytologic examination with Alcian blue, respectively. Nine patients with negative histologic but positive cytologic results were positive for intestinal metaplasia when they were reevaluated after further sectioning and staining. Sensitivity of imprint cytology alone was 53%. When imprint cytology was combined with the histologic evaluation, the prevalence of intestinal metaplasia increased from 27% to 38% (p < 0.05).

CONCLUSION

Imprint cytology might be a complementary diagnostic tool for histology in detecting patients with SSBE.

Specialized intestinal metaplasia and carditis at the gastroesophageal junction in Chinese patients undergoing endoscopy

OBJECTIVE

Specialized intestinal metaplasia (SIM) is often found at a normal-looking gastroesophageal junction on routine biopsy. The prevalence of SIM in Asian populations has not been recorded. Its significance is also unclear. The objective of the study was to document the prevalence of SIM at the gastroesophageal junction in a Chinese population undergoing endoscopy.

METHODS

Biopsies were taken at the gastroesophageal junction in 145 patients, both at the squamocolumnar junction and immediately below in the gastric cardia. Specimens were examined for the type of epithelium (squamous, cardiac, and fundic), the presence of SIM, and Helicobacter pylori (H. pylori).

RESULTS

Of 145 patients who underwent endoscopy, 136 had a normal-looking gastroesophageal junction. Cardiac epithelium was found in 100 patients. Of these 100 patients, SIM was documented in 34% of patients and carditis in 20%. Patients with SIM were older compared with those without SIM (mean age 62 yr and 56 yr, p = 0.035). Carditis was more prevalent in patients with SIM. It was present in 11 out of 34 patients who had SIM (32.4%) compared with nine in 66 patients (13.6%) without SIM, p = 0.036. When carditis was found, H. pylori was present at the cardia in 40% of patients (eight of 20) compared with only 18% (14 of 80) in those without carditis, p = 0.039.

CONCLUSIONS

SIM is prevalent at the gastroesophageal junction in Chinese patients undergoing endoscopy and is associated with carditis. Carditis in turn may be related to H. pylori infection.

Barrett oesophagus and adenocarcinoma: an overview of epidemiologic, conceptual and clinical issues

A steady increase in the incidence of adenocarcinoma of the oesophagus and oesophagogastric junction has been observed in Western countries. Patients with distinctive-type Barrett oesophagus are predisposed to developing adenocarcinoma of the oesophagus. Distinctive-type Barrett oesophagus is defined by the presence of intestinal-like goblet cells anywhere in the oesophagus. Adenocarcinomas of the oesophagogastric junction may be associated with short segments of intestinal-type columnar epithelium in the distal oesophagus. Prognosis after surgical resection for cancer of the oesophagus or oesophagogastric junction is strongly affected by the extent of the disease at the time of diagnosis. The identification of Barrett oesophagus as a premalignant condition, the recognition of a stepwise neoplastic progression, along with the poor survival rates of advanced oesophageal adenocarcinoma have initiated the practice of endoscopic biopsy surveillance for patients with Barrett oesophagus. There is supporting evidence that endoscopic biopsy surveillance of Barrett oesophagus permits detection of malignancy at an early stage with favourable results after oesophageal resection. Endoscopic treatment modalities should at this time not be generally adopted in the management of patients with early invasive adenocarcinoma of the oesophagus or oesophagogastric junction.

Carditis, intestinal metaplasia and adenocarcinoma of oesophagogastric junction

Barrett's oesophagus is a precancerous condition in which the normal squamous epithelium is replaced by intestinal metaplasia (IM). IM can then progress through increasingly severe dysplasia to oesophageal adenocarcinoma (EAC). In the gastric cardia the normal gastric mucosa, when inflamed (carditis), can be replaced by IM and can then progress to gastric adenocarcinoma (GAC). The same histopathological sequence can take place on either side of the oesophagogastric junction. Since the location of that junction can be uncertain this can result in confused diagnosis between EAC and GAC. In this review, the diagnostic criteria, incidence and risk factors for Barrett's oesophagus and carditis are discussed, together with the factors determining the risk of progression to adenocarcinoma of the oesophagus or cardia. The risk factors include familial/genetic, environmental and dietary characteristics. Finally, these risk factors are discussed within the context of cancer prevention.

Methylene blue chromoendoscopy for detection of short-segment Barrett's esophagus

BACKGROUND

The yield of intestinal metaplasia (IM) with randomly obtained biopsy specimens in patients with short lengths of columnar-appearing mucosa in the distal esophagus is low (30%-50%). Vital staining would be beneficial if it identified more patients with short-segment Barrett's esophagus (SSBE). Our aim was to compare the confirmation of IM in patients with suspected SSBE (columnar-appearing mucosa <3 cm in length) by using methylene blue (MB)-directed versus random biopsies.

METHODS

Consecutive patients undergoing EGD in whom columnar-appearing mucosa less than 3 cm in length was visualized underwent MB staining. Stained areas within suspected SSBE segments were targeted for biopsies. All biopsy specimens were stained with H & E with alcian blue at pH 2.5 and evaluated by a single pathologist. A historical control group (different from patients undergoing MB staining) consisted of patients with less than 3 cm of columnar-appearing mucosa in whom biopsy specimens were obtained randomly without MB staining.

RESULTS

The MB group included 75 patients (mean age 63.8 +/- 10.9 years) with a mean length of columnar-appearing mucosa of 1.2 cm (range 0.5-2.5 cm). The control group included 83 patients (mean age 60.5 +/- 12.9 years) with a mean length of columnar-appearing mucosa of 1.16 cm (range 0.5-2.5 cm). IM (i.e., confirmed SSBE) was detected in 61% of the MB group versus 42% of the control group (p = 0.0237). Patients in the MB group required significantly fewer biopsies (4.3 +/- 1.5 vs. 5.1 +/- 12.3, p = 0.0162). Confirmation of IM by length was as follows: less than 1 cm (irregular Z line), MB 17.4% versus control 25% (p = 0.73); 1 to less than 2 cm, MB 77% versus control 45% (p = 0.03); 2 to less than 3 cm, MB 90% versus control 58% (p = 0.02).

CONCLUSIONS

MB chromoendoscopy significantly increases the detection of IM and requires fewer biopsies in patients with suspected SSBE with greater than 1 cm of columnar-appearing mucosa. It does not appear to be beneficial in patients with irregular Z lines (<1 cm).

Timely topic: Premalignant lesions associated with adenocarcinoma of the upper gastrointestinal tract

The changing incidence of adenocarcinomas, particularly in the oesophagus and gastric cardia, has led to the rapid expansion of screening programmes aimed at detecting the precursor lesion of dysplasia before adenocarcinoma develops. The pathologist now has an important role in first diagnosing patients at risk for developing dysplasia, and then correctly classifying dysplasia when it occurs. Barrett's oesophagus has had different diagnostic criteria in previous years but is currently diagnosed by the presence of intestinal metaplasia of any length in the true oesophagus. Intestinal metaplasia confined only to the gastro-oesophageal junction or cardia is of uncertain significance but is probably common, with less risk of progressing to dysplasia or malignancy. In the stomach, patients with autoimmune atrophic gastritis and Helicobacter-associated multifocal atrophic gastritis have an increased risk of adenocarcinoma, but screening protocols are not well-developed compared with those used for Barrett's oesophagus. Dysplasia of glandular epithelium can be classified using well-described criteria. Low grade dysplasia is the most common type and regresses or remains stable in the majority of patients. High grade dysplasia is more ominous clinically, with a propensity to coexist with or progress to adenocarcinoma.

A postfundoplication study on Z-line appearance and intestinal metaplasia in the gastroesophageal junction

The purpose of this study was investigate the Z-line appearance by using a previously proposed classification, the ZAP classification, and to investigate the prevalence of intestinal metaplasia in the Z-line, among fundoplicated patients. Sixty patients, who had undergone fundoplication 2 to 17 years earlier, were included in the study. The prevalence of intestinal metaplasia was 20%. Intestinal metaplasia was found to be associated with age, more than 10 years of symptoms of gastroesophageal reflux disease preoperatively, tongues of columnar epithelium in the distal esophagus, carditis, and ZAP grade. ZAP grade, furthermore, was associated with male gender and more than 10 years of symptoms of gastroesophageal reflux disease preoperatively. Among patients with intestinal metaplasia, different ZAP grades can indicate different etiologic factors. Even among patients undergoing fundoplication (i.e., patients with an anatomically altered gastroesophageal junction), the ZAP classification is a feasible tool to characterize the Z-line appearance. The ZAP classification could prove valuable in selecting patients for follow-up treatment.

Short-segment Barrett's esophagus: findings on double-contrast esophagography in 20 patients

OBJECTIVE

The purpose of this study was to determine the findings of short-segment Barrett's esophagus on double-contrast esophagography.

MATERIALS AND METHODS

A review of pathology and endoscopy data revealed 142 patients with short-segment Barrett's esophagus, which was defined as columnar epithelium in the distal esophagus extending 3 cm or less above the gastroesophageal junction at endoscopy with histopathologic confirmation of intestinal metaplasia. Twenty of these patients underwent double-contrast esophagography. These 20 patients comprised our study group. The original radiology reports and images were reviewed to determine the findings on double-contrast esophagography. Medical records were also reviewed to determine the clinical findings and treatment.

RESULTS

Double-contrast esophagrams revealed hiatal hernias in 18 patients (90%), gastroesophageal reflux in 16 (80%), reflux esophagitis in seven (35%), peptic scarring or strictures in 11 (55%), and a reticular mucosal pattern in none. A total of 14 patients (70%) had morphologic findings of reflux disease with esophagitis alone (three patients), peptic scarring or strictures alone (seven patients), or both (four patients), but the remaining six (30%) had hiatal hernias or gastroesophageal reflux as the only radiographic finding.

CONCLUSION

Double-contrast esophagography revealed morphologic findings of reflux disease with esophagitis, peptic scarring or strictures, or both in 70% of patients with short-segment Barrett's esophagus. Thus, the absence of esophagitis or peptic scarring or strictures on double-contrast esophagography does not exclude the possibility of short-segment Barrett's esophagus.