Heterotopic gastric mucosa in the upper esophagus: report of a case with a fistula

Laryngopharyngeal symptoms and oesophageal disorder: The role of heterotopic gastric mucosa in upper oesophagus

BACKGROUND

Heterotopic gastric mucosa in the upper oesophagus (HGMUE) was considered as geneogenous manifestation. However, its clinical characteristics may be beyond our knowledge if we focus on its extra-oesophageal presentation. So the aim of this study was to investigate the relationship between HGMUE and laryngopharyngeal symptoms.

METHOD

Eight hundred and eleven patients who had gastric endoscopy examination were enrolled in this study and the cervical oesophagus was examined for the patch during withdrawal of the endoscope. Questionnaire for gastroesophageal reflux disease (GERD-Q) and Reflux Symptom Index (RSI) were completed by all the patients. Pathology feature and therapeutic effect of HGMUE patients were evaluated.

RESULT

About 34.53% of the patients undergoing the gastroduodenoscopy had laryngopharyngeal (LP) symptoms. The relevance rate of HGMUE in LP(+) group (10.69%) was higher than that in LP(-) group (2%). The LP symptoms were related to the histological type and expression of H+-K+-ATPase in the histological sample of HGMUE patients. The positive rate of H+-K+-ATPase was 100% in LP(+) group, and that in LP(-) group was 28.6%. PPI therapy was effective for improving the LP symptoms in HGMUE patients. The RSI score in LP(+) patients decreased from 8.12 ± 1.46 at baseline to 4 ± 0.74 at the end of 8 weeks after treatment of PPI.

CONCLUSION

HGMUE was an important cause of LP symptoms in patients, especially in those who had no evidence of GERD. The mechanism of HGMUE-induced LP symptoms was due to its location and the function of acid secretion according to the endoscopic finding and histologic characteristics.

Gastric inlet patches: symptomatic or silent?

PURPOSE OF REVIEW

The purpose of this review is to assess recent literature on the clinical relevance of the gastric inlet patch with particular focus on endoscopic diagnosis and treatment, the relationship of the inlet patch to laryngopharyngeal reflux disease and the association of proximal esophageal adenocarcinoma with inlet patch.

RECENT FINDINGS

Recent studies suggest endoscopic diagnosis of inlet patch increases with endoscopist awareness (up to 10-fold) and when using enhanced imaging techniques such as narrow band imaging (up to three-fold). The literature remains mixed on the association of inlet patch with laryngopharyngeal symptoms or globus sensation. Studies of endoscopic ablation, using argon plasma coagulation or radiofrequency ablation have shown improved laryngopharyngeal reflux symptom scores posttreatment. Proximal esophageal adenocarcinomas are rare but often associated with inlet patch when they occur. Case studies have described endoscopic resection of malignant lesions related to inlet patch, using endoscopic mucosal resection or submucosal dissection.

SUMMARY

Prospective, multicenter studies of symptom association with inlet patch using validated symptom questionnaires and blinded sham-controlled treatments are needed to further clarify the role of such treatments, which to date are limited to a small numbers of centers with a special interest.

Clinical significance of heterotopic gastric mucosal patch of the proximal esophagus

Heterotopic gastric mucosa of the proximal esophagus (HGMPE), also referred to as “inlet patch” or “cervical inlet patch”, is a salmon colored patch that is usually located just distal to the upper esophageal sphincter. HGMPE is uncommon with endoscopic studies reporting a prevalence ranging from less than one percent to 18%. Most HGMPE are asymptomatic and are detected incidentally during endoscopy for evaluations of other gastrointestinal complaints. Most consider HGMPE as clinically irrelevant entity. The clinical significance of HGMPE is mainly acid related or neoplastic transformation. The reported prevalence of laryngopharyngeal reflux symptoms varies from less than 20% to as high as 73.1%. However, most of these symptoms are mild. Clinically significant acid related complications such as bleeding, ulcerations, structure and fistulization have been reported. Although rare, dysplastic changes and malignancies in association with HGMPE have also been reported. Associations with Barrett’s esophagus have also been reported but the findings so far have been conflicting. There are still many areas that are unknown or not well understood and these include the natural history of HGMPE, risk factors for complications, role of Helicobacter pylori infection and factors associated with malignant transformations. Follow-up may need to be considered for patients with complications of HGMPE and surveillance if biopsies show intestinal metaplasia or dysplastic changes. Despite the overall low incidence of clinically relevant manifestations reported in the literature, HGMPE is a clinically significant entity but further researches are required to better understand its clinical significance.

Heterotopic gastric mucosal patch in patients with reflux laryngitis: an entity of clinical interest?

Heterotopic gastric mucosal patch (HGMP) in the upper esophagus has been suggested to play a role in the pathogenesis of laryngopharyngeal reflux. The aim of this study was to evaluate the prevalence and possible clinical significance of HGMPs in patients who underwent laparoscopic Nissen fundoplication for gastroesophageal reflux disease-induced reflux laryngitis.Forty consecutive patients with pH-proven reflux laryngitis referred to surgery by a specialist in otorhinolaryngology underwent laparoscopic Nissen fundoplication between 1998 and 2002. Twenty-seven (67.5%) of these patients underwent a postoperative upper gastrointestinal endoscopy paying special attention for detecting possible HGMPs in the proximal esophagus. When HGMP was found, biopsies were taken for histologic confirmation. A small histologically confirmed HGMP was detected in 1 out of 27 patients (3.7%). The prevalence of HGMPs in the upper esophagus in this specific patient group operated on for gastroesophageal reflux disease-induced reflux laryngitis equals the reported general prevalence rates of HGMPs detected in patients referred for upper gastrointestinal endoscopy as a part of gastrointestinal tract evaluation. The role of at least small HGMPs in the proximal esophagus in the pathogenesis of laryngopharyngeal reflux is clinically insignificant.

Esophageal motility and 24-h pH profiles of patients with heterotopic gastric mucosa in the cervical esophagus

BACKGROUND

Heterotopic gastric mucosa occurs as a flat island of red mucosa in the proximal third of the esophagus where it gives rise to the cervical inlet patch. The aims of this study were to investigate the esophageal motility pattern and 24-h pH profiles of patients with cervical inlet patch.

METHODS

Thirty patients (16 women, mean age: 44.9 years, range: 23-72) diagnosed as having heterotopic gastric mucosa in the cervical esophagus with upper gastrointestinal symptoms had undergone esophageal motility testing and 24-h pH monitorisation with a double-channel pH probe.

RESULTS

Manometric investigation was abnormal in 7 patients (non-specific esophageal motor disorder in 4 patients, esophageal hypomotility in 1 patient, and hypotensive LES in 2 patients). Pathological acid reflux (pH<4) was found in 9 (30%) of 30 heterotopic gastric mucosa patients during pH monitorisation from the distal probe. Pathological acid reflux in the proximal esophagus (percentage of total time of pH<4) was seen in four of these nine patients. Only four of the 30 patients (13.3%) presented with "acid independent episodes" during the 24-h esophageal pH monitorisation.

CONCLUSION

Manometric investigation and 24-h pH monitorisation revealed that some of the patients with HGM have signs of esophageal motor dysfunction and "acid independent episodes" from the patches. These abnormalities may be responsible for some of the symptoms of HGM patients.

[Heterotopic gastric mucosa in the upper esophagus. An unknown cause of dysphagia]

Heterotopic gastric mucosa in the proximal third of the esophagus is an embryological lesion that has been described in between 1.1% and 10% of gastroscopies. Although most of these lesions are asymptomatic, they can sometimes be accompanied by upper esophageal symptoms due to acid secretion. We present a case of heterotopic gastric mucosa in the proximal third of the esophagus with dysphagia. pH-metry demonstrated acid secretion by these lesions, which was resolved by treatment with proton pump inhibitors.

Heterotopic gastric mucosa: a significant clinical entity

OBJECTIVE

Despite the apparent lack of clinical interest in the inlet patches of heterotopic gastric mucosa (HGM) in the upper esophagus, the literature contains reports of complications associated with HGM. The aim of this study was to determine the prevalence and clinical importance of HGM in patients referred for upper gastrointestinal endoscopy (UGE).

MATERIAL AND METHODS

A total of 1033 consecutive outpatients referred for UGE were prospectively evaluated. Clinical, endoscopic and histologic findings were analyzed and 24-h double-channel pH-metry was performed on 20 patients with HGM.

RESULTS

Fifty-three patients (5.1%) had HGM lesions. Dysphagia was significantly more frequent in HGM patients (21% versus 4%; p<0.001). Five of the 20 patients who underwent pH-metry presented with acid secretion from HGMs. These five patients had inlet patches of greater size.

CONCLUSIONS

HGMs of the upper esophagus are not infrequent, although generally small and asymptomatic. In cases of large HGMs, acid secretion capacity may cause upper esophageal disorders.

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