Gastric heterotopia in the proximal esophagus complicated by stricture

Heterotopic Gastric Mucosa in the Proximal Esophagus: Prospective Study and Systematic Review on Relationships with Endoscopic Findings and Clinical Data

Cervical inlet patches (CIP) are common endoscopic findings with uncertain pathogenesis and clinical significance. We aimed to perform a systematic review and prospective study of clinical data and endoscopic findings related to CIP. It was a prospective single-center study conducted between 10/01/2017 and 9/01/2018. Forty patients with histopathologically confirmed CIP were compared with 222 individuals in the reference group. The systematic review was executed in accordance with the PRISMA guideline. Alcohol consumption tended to be higher among patients with CIP (3.0 ± 4.6 vs. 1.9 ± 5.0 standard drinks/week CIP patients and reference group, respectively; p < 0.001). Dysphagia was more frequent among patients with CIP (25% vs. 1.4%, CIP patients and reference group, respectively; p < 0.001), and sore throat and hoarseness were less frequent in patients with CIP (17.5% vs. 26.6% CIP patients and reference group, respectively; p < 0.01). In the multivariate regression analysis, the only risk factor of CIP occurrence was dysphagia (OR 21.9, 95%CI 4.9-98.6; p < 0.001). Sore throat and hoarseness were a reverse-risk factor of CIP diagnosis (OR 0.3, 95%CI 0.1-0.93; p = 0.04). Clinical data and coexisting endoscopic findings were not related to CIP. In the presented study, dysphagia was related to CIP occurrence, and sore throat and hoarseness tended to be less frequent among patients with CIP.

A, Ramesh NK, Shaikh MK. Heterotopic Gastric Mucosa in the Proximal Esophagus (Inlet Patch): Endoscopic Prevalence, Clinico-pathological Characteristics and Its Association with Helicobacter pylori

Objective To determine the prevalence of the inlet patch (IP), its clinico-pathological features, and its association with Helicobacter pylori.

Materials and Methods A prospective observational study was performed on 1,889 patients referred for esophagogastroduodenoscopy for various reasons, primarily for the evaluation of dyspepsia. All patients were enquired about the presence of symptoms and carefully examined for the presence of IP during upper gastrointestinal (GI) endoscopy. Biopsies were taken from the patients who had IP.

Statistical Analysis All statistical analyses were performed using the Statistical Package for Social Sciences (SPSS) 13.0 software for Windows XP. Categorical variables were compared using the chi-squared test or Fisher's exact test and continuous variables were compared using Student's t-test and univariate analysis. A P-value of less than 0.05 was considered to be statistically significant.

Results Inlet patches were found in 34 of 1,889 patients (1.8%). H. pylori was identified in 23.52% of patients (8/34) with IP. Gastric H. pylori infection was positive in all (08/08) patients who had IP. Colonization of H. pylori was more common in antral type mucosa (6/8). H. pylori positivity in the IP correlated with globus sensation symptom in our study, 87.5% of patients with IP and H. pylori positive had globus sensation.

Conclusion The prevalence of IP seems to be underestimated. H. pylori colonization of the IP is common and it positively correlates with globus sensation and is closely related to the H. pylori density in the stomach. Though preneoplasia within IP is rare, which does not support the recommendation to regularly obtain biopsies for histopathology, it might be beneficial in a subset of patients with persistent globus sensation.

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.

A rare association of inlet patch with laryngospasm: a report of two children and literature review

The inlet patch (IP) is an area of heterotopic gastric mucosa in the cervical esophagus commonly seen during upper endoscopy. Although generally asymptomatic IP has been associated with esophageal and supraesophageal symptoms and, though rare, in adult with malignant transformation. We describe two cases of recurrent episodes of laryngospasm associated with IP. In both cases there was a good response to prolonged acid suppression therapy.

Heterotopic gastric mucosa causing significant esophageal stricture in a 14-year-old child

Esophageal heterotopic gastric mucosa (HGM) is not uncommon and can be seen in up to 10% of the general population among numerous reports and epidemiologic studies which have been essentially performed in adult population. Pediatric data are still limited. Diagnosis requires clinician awareness of symptomatic cases who present with dysphagia or swallowing difficulties, and thorough endoscopic examination is crucial. Early detection of cases provides favorable clinical outcome and may prevent potential significant or serious long-term consequences such as esophageal stricture or web, Barrett's esophagus or malignant transformation in pediatric population. We reported a 14-year-old male who presented with 1-year history of gradually worsening dysphagia and was found to have two salmon-colored patches, which resemble gastric mucosa, in the proximal esophagus causing significant esophageal stricture. Gastric cardiac-type mucosa with acute and chronic inflammation was documented on biopsy. After several sessions of balloon dilation and endoscopic treatment, the HGM and esophageal stricture resolved and he became asymptomatic.

High oesophageal web formation in association with heterotopic gastric mucosa (the gastric inlet patch): a small case series

BACKGROUND

Upper oesophageal webs or rings have rarely been reported in association with heterotopic gastric mucosa (HGM).

OBJECTIVE

To describe the finding of oesophageal webs in association with HGM.

DESIGN

Small case series.

SETTING

Patients presenting with dysphagia to an open access hospital dysphagia clinic.

PATIENTS

Six cases were found.

INTERVENTIONS

Symptomatic improvement is demonstrated with oesophageal dilatation in symptomatic patients.

MAIN OUTCOME MEASUREMENTS

Symptomatic improvement.

RESULTS

The six cases which are described here demonstrate that a web or ring exactly matches the distribution of the heterotopic mucosa, can occur at both proximal and distal squamo-columnar junctions and the inlet patches may be multiple with multiple rings. A radiological double web sign is described.

LIMITATIONS

A rare condition with a small number of patients.

CONCLUSIONS

Effective treatment can be by oesophageal dilatation and acid suppression. The cause of web formation is thought to be due to heterotopic acid production and is analogous to the Schatzki ring.

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.

Is there an association between Helicobacter pylori in the inlet patch and globus sensation?

AIM: To determine the association between Helicobacter pylori (H. pylori) and globus sensation (GS) in the patients with cervical inlet patch.

METHODS: Sixty-eight patients with esophageal inlet patches were identified from 6760 consecutive patients undergoing upper gastrointestinal endoscopy prospectively. In these 68 patients with cervical inlet patches, symptoms of globus sensation (lump in the throat), hoarseness, sore throat, frequent clearing of the throat, cough, dysphagia, odynophagia of at least 3 mo duration was questioned prior to endoscopy.

RESULTS: Cervical heterotopic gastric mucosa (CHGM) was found in 68 of 6760 patients. The endoscopic prevalence of CHGM was determined to be 1%. H. pylori was identified in 16 (23.5%) of 68 patients with inlet patch. Fifty-three patients were classified as CHGM II. This group included 48 patients with globus sensation, 4 patients with chronic cough and 1 patient with hoarseness. All the patients who were H. pylori (+) in cervical inlet patches had globus sensation.

CONCLUSION: Often patients with CHGM have a long history of troublesome throat symptoms. We speculate that disturbances in globus sensation are like non-ulcer dyspepsia.

Heterotopic gastric mucosa (inlet patch): endoscopic prevalence, histopathological, demographical and clinical characteristics

OBJECTIVE

Heterotopic gastric mucosa (HGM) is found in the cervical oesophagus, just below the upper oesophageal sphincter, and has generally been overlooked by endoscopists. The objective of the present study is to determine endoscopic prevalence and histopathological and clinical characteristics of HGM and to classify patients according to their clinicopathological features.

METHOD

A total of 911 consecutive patients (436 M and 475 F) who were admitted to our Endoscopy Unit were examined. HGM type and the presence of Helicobacter pylori (Hp) either in the stomach or in the HGM were histopathologically evaluated.

RESULTS

Of the 911 patients, 33 (25 M and 8 F) were found to have HGM. HGM prevalence was determined to be 3.6%. On the basis of HGM patients' symptoms, only dysphagia was significantly correlated with the size of HGM (p < 0.05). Hp was positive in 29.2% of HGM. Clinicopathological classification of the patients showed that 20 patients were HGM type 1 and 13 were HGM type 2. None of the patients had HGM type 3, 4 or 5.

CONCLUSION

Prevalence of HGM was 3.6%. Dysphagia was found related with the size of HGM. This may be associated with larger HGMs' causing more acid secretion.

Large right atrial myxoma containing gastric heterotopia presenting with dyspnea and bilateral leg edema due to pulmonary emboli and cardiovascular obstruction: the first known report of gastric heterotopia in the cardiovascular system

A 52-year-old male presented with progressive dyspnea, bilateral leg edema, and elevated central venous pressure due to a large right atrial myxoma that caused vascular obstruction and pulmonary emboli. The myxoma contained gastric heterotopia. Other unusual features of this atrial myxoma included its large size, right atrial location, and attachment to the right atrial wall. Although gastric heterotopia has been reported throughout the gastrointestinal tract, and occasionally in other organs, this is the first report of gastric heterotopia in the cardiovascular system. This report confirms and extends previous reports of glandular elements or enteric glands within atrial, or cardiac, myxomas. The clinical presentation of the currently reported patient is explained as follows: the elevated central venous pressure resulted from cardiovascular obstruction and the dyspnea from multiple pulmonary emboli due to the large atrial myxoma. In this case, the clinical presentation was not attributable to the gastric heterotopia. The association of gastric heterotopia with atrial myxoma may, however, be clinically important because of the propensity of gastric heterotopia in the gastrointestinal tract to produce complications. The reported association may provide clues to the histogenesis of these two entities.

[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.

Inlet patch: heterotopic gastric mucosa--another contributor to supraesophageal symptoms?

OBJECTIVE

To determine prospectively the incidence of an inlet patch (IP) in children requiring esophagogastroduodenoscopy (EGD) and assess the prevalence of presenting symptoms between children with and without an IP.

STUDY DESIGN

All patients undergoing EGD in a 2-year period were assessed for the presence of an IP with biopsy confirmation. IP, distal esophagus, and stomach biopsy specimens were blindly reviewed by a pathologist for the presence and degree of inflammation and intestinal metaplasia. Symptoms from children with and without an IP were compared.

RESULTS

From 407 EGDs done by a single endoscopist, 24 patients had confirmed IP (incidence of 5.9%). The presence and degree of inflammation were always relatively greater in the columnar mucosa of the IP than in the antral/body gastric mucosa in the same patient (P = .0027) Inflammation was similar in the squamous epithelium around the IP and in the distal esophagus (P=.46). Two patients had intestinal metaplasia of the IP. The patients with IPs had a higher prevalence of respiratory symptoms than the control group (P = .03).

CONCLUSIONS

Children with IPs may have a higher frequency of respiratory symptoms. Periodic surveillance should be performed in children with intestinal metaplasia of an IP.

Heterotopic gastric mucosa of the esophagus: literature-review and proposal of a clinicopathologic classification

The prevalence of heterotopic gastric mucosa (HGM) in the cervical esophagus is frequently underestimated. Tiny microscopic foci have to be distinguished from a macroscopically visible patch, also called "inlet patch." Symptoms as well as morphologic changes associated with HGM are regarded as a result of the damaging effect of acid, produced by parietal cells in the mostly fundic type of HGM. We herein review the literature and propose a new clinicopathologic classification of esophageal HGM: Most of the carriers of esophageal HGM are asymptomatic (HGM I). Some individuals with HGM in the esophagus complain of dysphagia, odynophagia, or "extraesophageal manifestations" (hoarseness and coughing), without further morphologic findings (HGM II). Still fewer patients are symptomatic due to morphologic changes, i.e., esophageal strictures, webs, or esophagotracheal fistula (HGM III). Malignant transformation via dysplasia (intraepithelial neoplasia, HGM IV) to cervical esophageal adenocarcinoma (HGM V) is exceedingly rare (only 24 reported cases). In contrast to Barrett's esophagus, HGM should not be regarded as a precancerous lesion. Symptoms are more likely to occur in patients with inlet patch, whereas malignant transformation and adenocarcinogenesis can also occur in microscopic HGM foci. Asymptomatic HGM requires neither specific therapy nor endoscopic surveillance. Only in symptomatic cases treatment, i.e., dilatation for (benign) strictures or acid suppression for reflux symptoms, can be recommended. Patients with low-grade dysplasia in HGM might be candidates for surveillance strategies, whereas in cases of high-grade dysplasia and invasive adenocarcinoma oncological treatment strategies must be employed.