Prevalence and risk factors of Barrett's esophagus in Korea

Understanding the Columnar Lined Esophagus and Its Variations in Length With Age: A Cadaveric Study

Introduction Columnar lined epithelium (CLE) of the esophagus holds particular importance in diagnosing Barrett's esophagus (BE). In Asia, the prevalence of BE ranges from 0.06% to 6.2%. In India, prevalence estimates vary from 2.6% to 23%. The frequency of esophageal adenocarcinoma has also been observed to be increasing alarmingly over the past few decades. The length of CLE as a criterion for diagnosing BE is the subject of considerable debate. Changes in CLE length among different age groups may exist. Our study aims to measure the length of CLE, or the distance between the angle of His and the Z Line (AZ distance), in normal individuals from Northeast India, and to analyze its variation across different age groups. Materials and methods The study was conducted in the Department of Anatomy and the Department of Forensic Medicine and Toxicology at Gauhati Medical College, Guwahati, Assam, India, during the period 2017-2019. Once opened, each specimen was laid flat on a board. The distance between the A and Z lines was measured using a pair of vernier calipers. This distance was recorded as the AZ distance in millimeters (mm). Results The mean AZ Distance was found to be 12.4 ± 5.3 mm. A significant correlation between age and AZ distance was observed. Conclusion Our present study suggests that the length of the CLE increases with age. This observation offers an opportunity to revisit or revise the diagnostic criteria based on CLE length, taking into account the age of the individual.

Prevalence of Barrett's esophagus in a Southern European country: a multicenter study

BACKGROUND

Identification of Barrett's esophagus (BE) with the treatment of dysplasia is essential to prevent esophageal adenocarcinoma (EAC). Moreover, determination of BE prevalence is important to define subsequent management strategies. However, precise estimates on BE prevalence from several European countries are lacking. We aimed to determine BE prevalence in a Southern European country.

METHODS

A cross-sectional, multicenter study from November 2019 to February 2020 was performed defining BE as a columnar extent in the distal esophagus greater than or equal to 1 cm with intestinal metaplasia.

RESULTS

A total of 1550 individuals, 51% male with a mean age of 62 (SD = 15) years undergoing upper endoscopy were included. The overall BE prevalence was 1.29% (95% confidence interval: 0.73-1.85); significantly higher in men [2.05% (1.06-3.04)] vs. women [0.53% (0.01-1.04)]. Of the 20 BE patients, eight were newly diagnosed and 12 were under surveillance. The median extent was C3 (min 0; max 16) M4.5 (min 2; max 16). One patient each had EAC (0.06%) and high-grade dysplasia (0.06%) at the time of endoscopy. There was no difference in prevalence between geographical regions, centers, use of sedation or experience of endoscopists. Considering all reports, 93% used standardized terminology, 23% accurate photodocumentation and 69% photodocumented the esophagogastric junction (EGJ). Furthermore, 80% used Prague classification, 55% Seattle protocol, 60% distance to the squamocolumnar junction, 75% to the EGJ and 40% to the hiatal pinch. When considering only reports with EGJ photodocumentation or Prague classification, the prevalence was 1.78% (0.91-2.64) or 1.03% (0.53-1.53).

CONCLUSION

We report for the first time BE prevalence in Southern Europe and report a low overall prevalence in an unselected population. Future studies need to determine progression rates and how to improve quality metrics.

The global prevalence of Barrett's esophagus: A systematic review of the published literature

BACKGROUND

Determining the prevalence of Barrett's esophagus is important for defining screening strategies. We aimed to synthesize the available data, determine Barrett's esophagus prevalence, and assess variability.

METHODS

Three databases were searched. Subgroup, sensitivity, and meta-regression analyses were conducted and pooled prevalence was computed.

RESULTS

Of 3510 studies, 103 were included. In the general population, we estimated a prevalence for endoscopic suspicion of Barrett's esophagus of (a) any length with histologic confirmation of intestinal metaplasia as 0.96% (95% confidence interval: 0.85-1.07), (b) ≥1 cm of length with histologic confirmation of intestinal metaplasia as 0.96% (95% confidence interval: 0.75-1.18) and (c) for any length with histologic confirmation of columnar metaplasia as 3.89% (95% confidence interval: 2.25-5.54) . By excluding studies with high-risk of bias, the prevalence decreased to: (a) 0.70% (95% confidence interval: 0.61-0.79) and (b) 0.82% (95% confidence interval: 0.63-1.01). In gastroesophageal reflux disease patients, we estimated the prevalence with afore-mentioned criteria to be: (a) 7.21% (95% confidence interval: 5.61-8.81) (b) 6.72% (95% confidence interval: 3.61-9.83) and (c) 7.80% (95% confidence interval: 4.26-11.34). The Barrett's esophagus prevalence was significantly influenced by time period, region, Barrett's esophagus definition, Seattle protocol, and study design. There was a significant gradient East-West and North-South. There were minimal to no data available for several countries. Moreover, there was significant heterogeneity between studies.

CONCLUSION

There is a need to reassess the true prevalence of Barrett's esophagus using the current guidelines in most regions. Having knowledge about the precise Barrett's esophagus prevalence, diverse attitudes from educational to screening programs could be taken.

Global Prevalence and Risk Factors of Gastro-oesophageal Reflux Disease (GORD): Systematic Review with Meta-analysis

Although gastro-oesophageal reflux disease (GORD) is a common medical complaint, there is currently no consensus on the global prevalence of GORD. The aim of this study was to conduct a systematic review and meta-analysis on GORD prevalence and risk factors at a global level. MEDLINE, EMBASE, CINAHL, Scopus, Cochrane library, and Google Scholar were systematically searched, without language restrictions, for studies on the prevalence and risk factors of GORD. Data were pooled using a random effects model (95% confidence interval), and the odds ratio and relative risk for each risk factor were calculated. Out of 34,355 search results, 96 records reporting the results from 102 studies fulfilled the inclusion criteria, representing 37 countries and all regions of the UN geoscheme. The global pooled prevalence of GORD was 13.98% and varied greatly according to region (12.88% in Latin America and the Caribbean to 19.55% in North America) and country (4.16% in China to 22.40% in Turkey). Using the United Nations 2017 Revision of World Population Prospects, the estimated number of individuals suffering from GORD globally is 1.03 billion. Multiple risk factors associated with a significant increase in the risk of GORD were also identified. This systematic review and meta-analysis revealed that although a substantial proportion (13.98%) of the global population suffers from GORD, there are significant variations between regions and countries. Risk factors for GORD were also identified which may allow clinicians to recognise individuals most at risk.

Systematic review and meta-analysis of prevalence and risk factors for Barrett's esophagus

BACKGROUND AND AIMS

Although screening for Barrett's esophagus (BE) is recommended in individuals with multiple risk factors, the type and number of risk factors necessary to trigger screening is unclear. In this systematic review and meta-analysis, we aimed to assess the relationship between number of risk factors and prevalence of BE.

METHODS

Through October 17, 2018 we searched studies that described the prevalence of BE in the general population and based on presence of risk factors that included GERD, male gender, age >50 years, family history of BE and esophageal adenocarcinoma, and obesity (defined as body mass index >35). Risk of BE based on number of risk factors was assessed using meta-regression while controlling for potential confounders.

RESULTS

Of 2741 studies, 49 were included in the analysis (307,273 individuals, 1948 with biopsy specimen-proven BE). Indications varied by study. The prevalence of BE for various populations was as follows: low-risk general population, .8% (95% confidence interval [CI], .6%-1.1%); GERD, 3% (95% CI, 2.3%-4%); GERD plus presence of any other risk factor, 12.2% (95% CI, 10.2%-14.6%); family history, 23.4% (95% CI, 13.7% -37.2%); age >50, 6.1% (95% CI, 4.6%-8.1%); obesity, 1.9% (95% CI, 1.2%-3%); and male sex, 6.8% (95% CI, 5.3%-8.6%). Prevalence of BE varied significantly between Western and non-Western populations. In a meta-regression, controlling for the region of the study, age, and gender, there was a positive linear relationship between the number of risk factors and the prevalence of BE.

CONCLUSIONS

Results of this study provide estimates of BE prevalence based on the presence and the number of risk factors. These results add credence to current guidelines that suggest screening in the presence of multiple risk factors.

Evaluation of p53 protein expression in Barrett esophagus

Background

Loss of heterozygosity of p53 along with aneuploidy is deemed to be the early molecular steps in Barrett metaplasia-dysplasia-adenocarcinoma sequence. Objective biomarkers need to be used along with microscopy for risk stratification to predict the progression of Barrett esophagus (BE) to carcinoma.

Aim

This study aims to study p53 protein expression in dysplasia and correlate the same with morphology in BE.

Materials and Methods

A time-bound study was conducted from January 2011 to June 2015. All esophageal biopsies showing histological evidence of columnar epithelium with the presence of goblet cells were included. The cases which showed dysplasia were graded on hematoxylin and eosin stain. Evaluation of p53 immunohistochemistry staining was done on all the cases of BE. Dysplasia was correlated with the expression of p53 using Chi-square value (χ²) and Fischer's exact test wherever appropriate. P < 0.05 was considered to be statistically significant.

Results

Of 829 esophageal biopsies received, 119 were endoscopically suspected to be BE, of which 85 cases were confirmed on microscopy. In our study, there were 75 cases negative for dysplasia (88.2%), 8 with low-grade dysplasia (LGD) (9.4%), and two with high-grade dysplasia (HGD) (2.4%). Three cases of BE had associated adenocarcinoma. Immunostaining with p53 done on all the 85 cases showed positive staining in all cases with LGD, one with HGD and two with adenocarcinoma. In the present study, immunostaining with p53 showed 90% sensitivity, 89.3% specificity, positive predictive value of 52.9%, and negative predictive value of 98.5%.

Conclusion

The technical simplicity, easy availability, and comparatively lower cost enhance the role of p53 as a biomarker in risk stratification for patients with BE.

Impact of Obesity on a Chinese Population with Erosive Esophagitis and Barrett's Esophagus

Background/Aims

The aim of this study was to investigate the associations between obesity and erosive esophagitis (EE) or Barrett's esophagus (BE) in a Chinese population.

Methods

Data from subjects were retrospectively collected from 2006 to 2009. Individuals with BE were identified and age- and sex-matched at a 1:2 ratio with normal esophagocardial junction and EE patients. The subjects were stratified into two groups: the normal weight group and overweight/ obesity group (body mass index ≥25 mg/m²) or the normal waist group and abdominal obesity group (waist circumference ≥90 cm for men and ≥80 cm for women).

Results

Overall, 45%, 72%, and 52% were overweight/obese and 23%, 65%, and 18% had abdominal obesity in the normal, EE, and BE groups, respectively. Positive associations were identified between EE and overweight/obesity (odds ratio [OR], 3.14; 95% confidence interval [CI], 1.75 to 5.66) and abdominal obesity (OR, 6.22; 95% CI, 3.34 to 11.57); however, the associations were nonsignificant between BE and overweight/obesity (OR, 1.32; 95% CI, 0.67 to 2.61) or abdominal obesity (OR, 0.73; 95% CI, 0.31 to 1.73). Female BE patients had a significantly increased rate of being overweight/obese.

Conclusions

Obesity is a contributing factor in EE. The association of BE and obesity was not significant, with the exception of female BE cases.

Sex and Gender Differences in Gastroesophageal Reflux Disease

It is important to understand sex and gender-related differences in gastroesophageal reflux disease (GERD) because gender-related biologic factors might lead to better prevention and therapy. Non-erosive reflux disease (NERD) affects more women than men. GERD symptoms are more frequent in patients with NERD than in those with reflux esophagitis. However, men suffer pathologic diseases such as reflux esophagitis, Barrett's esophagus (BE), and esophageal adenocarcinoma (EAC) more frequently than women. The prevalence of reflux esophagitis is significantly increased with age in women, especially after their 50s. The mean age of EAC incidence in women is higher than in men, suggesting a role of estrogen in delaying the onset of BE and EAC. In a chronic rat reflux esophagitis model, nitric oxide was found to be an aggravating factor of esophageal injury in a male-predominant way. In addition, the expression of esophageal occludin, a tight junction protein that plays an important role in the esophageal defense mechanism, was up-regulated in women. This explains the male predominance of reflux esophagitis and delayed incidence of BE or EAC in women. Moreover, the symptoms such as heartburn, regurgitation, and extra-esophageal symptoms have been more frequently reported by women than by men, suggesting that sex and gender play a role in symptom perception. Differential sensitivity with augmented symptoms in women might have diagnostic and therapeutic influence. Furthermore, recent studies have suggested that hormone replacement therapy has a protective effect against esophageal cancer. However, an anti-inflammatory role of estrogen remains compelling, which means further study is necessary in this area.

The Genetics of Barrett's Esophagus: A Familial and Population-Based Perspective

Barrett's esophagus (BE) is intestinal metaplasia of the lower esophagus and a precursor lesion for esophageal adenocarcinoma (EAC). Both are important health issues as they have rising incidences in the Western world. Improving the management of BE relies on understanding the underlying biology of this disease, but the exact biological mechanisms have been difficult to determine. BE is generally thought to be an acquired condition that develops secondarily to chronic gastroesophageal reflux. However, multiple reports of familial clustering of patients with BE and/or EAC suggest a possible inherited predisposition to BE may be driving this condition, at least in a subset of patients. Identifying the genetic variants that predispose to BE in these families would open up the possibility for blood-based screening tests that could inform decision-making in regard to surveillance strategies, particularly for relatives of patients with BE and/or EAC. Perhaps more importantly, understanding the genetic mechanisms that predispose to BE may provide valuable insights into the biology of this condition and potentially identify novel targets for therapeutic intervention. Here we review the current evidence for a genetic predisposition to BE and discuss the potential implications of these findings.

Application of the Prague C and M criteria for endoscopic description of columnar-lined esophagus in South Korea

AIM: To ascertain whether the Prague circumferential (C) length and maximal (M) length criteria for grading the extent of Barrett’s esophagus can be applied prior to its widespread application in South Korea.

METHODS: Two hundred and thirteen consecutive cases with endoscopic columnar-lined esophagus (CLE) were included and classified according to the Prague C and M criteria.

RESULTS: Of 213 cases with CLE, the distribution of maximum CLE lengths was: 0.5-0.9 cm in 99 cases (46.5%); 1.0-1.4 cm in 63 cases (29.6%); 1.5-1.9 cm in 15 cases (7.0%); 2.0-2.4 cm in 14 cases (6.6%); 2.5-2.9 cm in 1 case (0.5%); and 7.0 cm in 1 case (0.5%). Twenty cases (9.4%) had columnar islands alone. Two hundred and eight cases (97.7%) lacked the circumferential CLE component (C0Mx). Columnar islands were found in 70 cases (32.9%), of which 20 cases (9.4%) had columnar islands alone.

CONCLUSION: In regions where most CLE patients display short or ultrashort tongue-like appearance, more detailed descriptions of CLE’s in < 1.0 cm lengths and columnar islands, as well as avoidance of repeating the prefix “C0” need to be considered in parallel with the widespread application of the Prague system in South Korea.

Risk factors for Barrett's esophagus

Barrett's esophagus (BE) is a well-recognized precursor of esophageal adenocarcinoma (EAC) and is defined as ≥1 cm segment of salmon-colored mucosa extending above the gastroesophageal junction into the tubular esophagus with biopsy confirmation of metaplastic replacement of the normal squamous epithelium by intestinal-type columnar epithelium. The incidence of both BE and EAC has been increasing over the past few decades. As a result, preventing the development of BE by identifying and understanding its modifiable and non-modifiable risk factors may help reduce the incidence of EAC. Over the recent past, a tremendous amount of progress has been made towards improving our knowledge of risk factors and pathogenesis of BE. This article reviews the evidence for the various risk factors for developing BE.

Prevalence of Barrett's Esophagus in Asian Countries: A Systematic Review and Meta-analysis

BACKGROUND & AIMS

The prevalence and risk factors of Barrett's esophagus (BE) in Asian countries are unclear. Studies report a wide range of BE prevalence in Asian countries. We conducted a systematic review and meta-analysis to examine the prevalence of BE and its temporal changes and risk factors in Asian countries.

METHODS

Two investigators performed independent literature searches by using PubMed and EMBASE databases, and subsequent data abstraction for studies had to meet several set inclusion and exclusion criteria. Pooled BE prevalence was calculated by using a random-effect model. Estimates of relative risk for possible risk or protective factors were also calculated.

RESULTS

A total of 51 studies (N = 453,147), mainly from Eastern Asia, were included. The pooled prevalence of endoscopic BE was 7.8% (95% confidence interval, 5.0-12.1; 23 studies) and of histologically confirmed BE was 1.3% (95% confidence interval, 0.7-2.2; 28 studies). Most of histologic BE (82.1%) was short-segment BE (<3 cm). There was a trend toward an increase in prevalence of BE over time from 1991 to 2014, especially in Eastern Asian countries. Within BE cohorts, pooled prevalence of low-grade dysplasia, high-grade dysplasia, and esophageal adenocarcinoma was 6.9%, 3.0%, and 2.0%, respectively. Reflux symptoms, male sex, hiatus hernia, and smoking were associated with a significantly increased risk of histologic BE in patients with BE compared with patients without BE. However, half of the patients with histologic BE did not have reflux symptoms.

CONCLUSIONS

BE is not uncommon in Asian countries and seems to share similar risk factors and potential for neoplastic progression to those seen in Western countries.

Does Sedation Affect Examination of Esophagogastric Junction during Upper Endoscopy?

PURPOSE

During sedated esophagogastroduodenoscopy (EGD), patients may not be able to perform inspiration, which is necessary to examine the esophagogastric junction. Therefore sedation may affect diagnosis of gastroesophageal reflux-related findings. The aim of our study was to investigate the effect of sedation on diagnosis of gastroesophageal reflux-related findings during EGD.

MATERIALS AND METHODS

This retrospective study evaluated 28914 patients older than 20 years who underwent EGD at our institution between January 2011 and December 2011. Ultimately, 1546 patients indicated for EGD for health check-up and symptom evaluation were included.

RESULTS

There were 18546 patients who had diagnostic EGD: 10471 patients (56%) by non-sedated EGD and 8075 patients (43%) by sedated EGD. After statistical adjustment for age, sex, and body mass index, minimal change esophagitis, and hiatal hernia were significantly less frequently observed in the sedated EGD group [odds ratio (OR), 0.651; 95% confidence interval (CI), 0.586 to 0.722 and OR, 0.699; 95% CI, 0.564 to 0.866]. Nevertheless, there was no significant difference in other findings at the gastroesophageal junction, such as reflux esophagitis with Los Angeles classification A, B, C, and D or Barrett's esophagus, between the two groups. Similarly, there were no differences in early gastric cancer, advanced gastric cancer, and gastric ulcer occurrence.

CONCLUSION

Sedation can impede the detection of minimal change esophagitis and hiatal hernia, but does not influence detection of reflux esophagitis of definite severity and Barrett's esophagus.

Association Between Alcohol Consumption and the Risk of Barrett's Esophagus: A Meta-Analysis of Observational Studies

The association between alcohol consumption and Barrett's esophagus (BE) remained uncertain and controversial in the previous studies. We performed a meta-analysis of observational studies to clarify the association.We searched PubMed, Web of Science, and Embase for studies on alcohol consumption and risk of BE published before February 2015. A total of 20 studies reporting the association between alcohol consumption and the risk of BE were identified. Subgroup analyses, meta-regression analyses, sensitivity analyses, and publication bias tests were also performed. Several results from individual studies were pooled using a dose-response meta-analysis.A total of 20 studies involving 45,181 participants and 4432 patients of BE were included in the meta-analysis. No association was found between alcohol consumption and BE (relative risk [RR] = 1.10, 95% confidence interval [CI] 0.96-1.27, I = 48.60%) in our study. In subgroup analysis, alcohol consumption was associated with an increased risk of BE in men (RR = 1.35, 95% CI 1.13-1.61, I = 0.00%) and Asian population (RR = 1.60, 95% CI 1.03-2.49, I = 60.60%). In beverage-specific consumption analysis, liquor was associated with an increased risk of BE (RR = 1.16, 95% CI 1.02-1.32, I = 0.00%). Multivariate meta-regression analysis suggested that geographic area, and adjusted age, sex, body mass index, and smoke, might explain 70.75% of the heterogeneity between the studies. We also found the inverse association (RR = 0.84, 95% CI 0.72-0.98, I = 0.00%) between alcohol consumption and BE among subjects when compared with population controls.Overall, there was no significant association between alcohol consumption and BE. Alcohol consumption may be a risk factor of BE in men and Asian population, and liquor consumption may also increase the risk of BE. Significant inverse association was observed between alcohol consumption and BE, for comparisons with population controls.

Utility of endoscopy for diagnosis of barrett in a non-Western society: endoscopic and histopathologic correlation

Barrett esophagus is metaplastic transformation of esophageal squamous epithelium to columnar cells. A total of 1370 patients who had undergone upper endoscopy because of dyspeptic complaints were enrolled in the study. Age, sex, alcohol and smoking habits, body mass index, type and duration of symptoms (heartburn, epigastric pain, nausea, vomiting), and use of proton pump inhibitors were evaluated in all patients and recorded on standardized forms. Patients were grouped as normal esophagogastric junction, long-segment Barrett esophagus, and short-segment Barrett. Biopsies were taken from at least 6 points and examined histopathologically. Of the 1370 patients involved in the study, 748 (54.6%) were female and 622 (45.4%) were male. Mean age was 47.2 ± 15.30 years. Short-segment Barrett esophagus was detected in 16 patients, and long-segment Barrett was detected in 11 patients. Although Barrett esophagus was detected in 11 cases that were suspected to have Barrett during endoscopy, histopathology was negative in all cases that were not suspected to have Barrett. Barrett esophagus prevalence was significantly higher in people who used alcohol and tobacco and who had hiatal hernia. Although Barrett esophagus was detected in 40% of cases that were suspected to have Barrett during endoscopy, histopathology was negative in all cases that were not suspected to have Barrett. Barrett was detected in 40.7% of cases that were suspected to have Barrett during endoscopy; histopathology was negative in all cases that were not suspected to have Barrett. Senstivity of endoscopy is questionable in detection of short-segment Barrett.

Alcohol consumption and the risk of Barrett’s esophagus: A meta-analysis

AIM: To evaluate the possible association between alcohol consumption and Barrett’s esophagus (BE).

METHODS: We performed a systematic literature search of multiple online electronic databases. Inclusion criteria entailed studies about alcohol and BE. Meta-analysis was conducted to evaluate odds ratio (OR) and 95%CIs for the association between alcohol consumption and BE.

RESULTS: Twenty studies comprising 4758 patients with BE were included in the meta-analysis. The risk of BE in patients with alcohol consumption was increased compared with control groups (OR = 1.01; 95%CI: 1.00-1.02), especially in case-control and cohort, European and Asian, and hospital studies, but there was a decreased risk of BE associated with alcohol consumption from American studies (OR = 0.86; 95%CI: 0.77-0.96). At the same time, there was no significant association between BE and alcohol consumption in community studies (OR = 0.97; 95%CI: 0.84-1.12) and the type of alcohol (wine, beer and liquor) studies.

CONCLUSION: Our meta-analysis found that alcohol consumption was associated with an increased risk of BE, especially for European and Asian drinkers.

Barrett esophagus in Asia: same disease with different pattern

Barrett esophagus (BE) is considered to develop as a result of chronic gastroesophageal reflux disease (GERD) and to predispose to esophageal adenocarcinoma (EAC). However, the disease pattern of BE in Asia differs from that observed in the West. For example, in the West, the prevalence rates of BE and EAC have progressively increased, whereas although the prevalence rate of GERD is increasing in Asia, the prevalence rates of BE and EAC have remained low in most Asian countries. GERD, hiatal hernia, old age, male sex, abdominal obesity (visceral obesity), smoking, alcohol consumption, and kyphosis are known risk factors for BE in Asia, and most Asian patients have short-segment BE. Helicobacter pylori infection is more prevalent in Asia than in the West. We suggest larger studies with a prospective design be conducted to elaborate further the different patterns of BE in Asia.

Cigarette smoking and the risk of Barrett's esophagus: a systematic review and meta-analysis

BACKGROUND AND AIM

Barrett's esophagus (BE) is a premalignant condition to esophageal adenocarcinoma. It is currently not clear whether cigarette smoking increases the risk of developing BE, and no meta-analysis has been performed on the topic. We conducted a systematic review and meta-analysis, providing a quantitative estimate of the increased risk of BE associated with cigarette smoking, to help clarify whether a relationship exists between smoking and BE.

METHODS

Four electronic databases (Medline, PubMed, Embase, and Current Contents Connect) were searched to May 17, 2013, for observational studies of BE patients. We calculated pooled odds ratios (ORs) and 95% confidence intervals (CIs) using a random effects model for the association of smoking with BE. BE patients were compared with non-gastroesophageal reflux disease (GERD) controls as well as with population-based and GERD controls.

RESULTS

Thirty-nine studies comprising 7069 BE patients were included in the meta-analysis. Having ever-smoked was associated with an increased risk of BE compared with non-GERD controls (OR 1.44; 95% CI 1.20-1.74), population-based controls (OR 1.42; 95% CI 1.15-1.76), but not GERD controls (OR 1.18; 95% CI 0.75-1.86). The meta-analyses of the studies reporting the lowest and highest number of pack-years smoked showed an increased risk of BE (OR 1.41; 95% CI 1.22-1.63) and (OR 1.53; 95% CI 1.27-1.84), respectively.

CONCLUSION

Cigarette smoking was associated with an increased risk of BE. Being an ever-smoker was associated with an increased risk of BE in all control groups. A greater number of pack-years smoked was associated with a greater risk of BE.

[The prevalence of Barrett's esophagus and the comparison of Barrett's esophagus with cardiac intestinal metaplasia in the health screening at a secondary care hospital]

BACKGROUND/AIMS

The purpose of this study was to estimate the prevalence of Barrett's esophagus (BE) and its association with reflux esophagitis (RE) and peptic ulcer disease detected by free charge endoscopy which was covered by the National Health Insurance at a secondary care hospital, and to compare the results of the biopsy of BE with that of cardiac intestinal metaplasia (CIM).

METHODS

A total of 4,002 patients underwent endoscopy from March 2010 to December 2012. BE was diagnosed if there was histologically proven specialized intestinal metaplasia, and CIM was diagnosed if intestinal metaplasia was accompanied with chronic gastritis.

RESULTS

Four hundred twenty four patients underwent endoscopic biopsy, and the prevalence of BE was 1.0% (42/4,002). The mean age and the proportion of males in BE were significantly higher than those of the rest of study population, and BE had slight tendency related to RE than the rest of study population. CIM was observed in 34 patients and BE and CIM showed similar results, regarding age, sex and association with RE. The mean length of endoscopic Barrett's mucosa of BE group was 9.2±5.1 mm, and it was similar to that of CIM.

CONCLUSIONS

The prevalence of BE in the secondary care hospital was not low, and old age and male sex were significantly associated with BE. Because BE was observed in about 10% of biopsied patients and CIM was observed in a similar percentage with BE, the precise targeted biopsy is warranted and the biopsy method should be reestablished through the large prospective study of multiple secondary care hospitals.

Prevalence and pathogenesis of Barrett's esophagus in Luoyang, China

BACKGROUND

Prevalence of Barrett's esophagus (BE) in Luoyang, China, has not been reported, and its pathogenesis is controversial. The aim of this study was therefore to investigate the prevalence of BE and its underlying factors in the city of Luoyang.

METHOD

This was a prospective study in one center. Many patients were analyzed using endoscopy who showed upper gastrointestinal symptoms between August 2006 and June 2007. In addition, the effect of apoptosis-related proteins and heat shock proteins upon BE's pathogenesis were also investigated by an immunohistochemical protocol.

RESULTS

Prevalence of BE was at 4.55% and the mean age of those affected was about 10 years older than for esophagitis. Typical reflux symptoms were significantly lower than with esophagitis, whereas signs of caspase-3 and HSP105 elevation were significantly higher. Expression of TERT, HSP70 and HSP90α in BE cases was significantly lower than in esophagitis. However, there was no statistical difference between the two groups in expression of HSP27.

CONCLUSIONS

The prevalence of BE is high in Luoyang, which could result from esophagitis despite typical reflux symptoms being relatively uncommon. Initiation and development of BE might be the result of accelerated proliferation, apoptosis and differentiation of original cells to intestinal epithelium.

Barrett's oesophagus in Asians--are ethnic differences due to genes or the environment?

Ethnic differences in the prevalence of gastro-oesophageal reflux disease (GORD) and its complications, including Barrett's oesophagus (BO), are well described in multiracial Asian patient populations. These findings together with familial aggregation of GORD symptoms and twin studies suggest the possibility of a genetic component to GORD. Nevertheless, environmental factors, e.g. Helicobacter pylori infection, abdominal adiposity and metabolic syndrome, could equally account for these differences. Indian (South Asian) race is a risk factor for Barrett' oesophagus. This may be related to the Caucasian genetic make-up of Indians as opposed to an Oriental one as is the case of most other Asians. The HLA-B07 gene commonly found in South Asian and Caucasian populations, but not Orientals, may confer an increased risk for BO. Nevertheless, the high prevalence of H. pylori in South Asians and the consequent atrophic gastritis and hypochlorhydria may partially ameliorate this genetic predisposition to BO. The higher prevalence of obesity and the metabolic syndrome amongst certain Asiatic races may also contribute to the observed increased risk for BO. Future research should target the search for GORD/BO genes, ethnic differences in parietal cell mass and hiatal hernia, H. pylori colonization factors (e.g. MUC1 and MUC2) and adhesion molecules (BabA). Racial differences in lifestyle factors, i.e. abdominal adiposity, consumption of fruit and vegetables as well as smoking, should all be investigated as potential causes for this interethnic variation in GORD and BO. Nature or nurture, the clues are teasing and tantalizing and illustrate the complex relationship between the genetic make-up of man and the environment.

Management of cancer risk in Barrett's esophagus

The importance of Barrett's esophagus (BE) lies in its potential to give rise to esophageal adenocarcinoma (EAC), postulated to be through a series of progressive degrees of dysplasia; from intestinal metaplasia to low-grade dysplasia, high-grade dysplasia, and subsequently, to cancer. The management strategies for the detection and treatment of dysplasia and early esophageal cancer on a background of BE have changed significantly in the last few decades, with the emergence of newer and less invasive non-operative alternatives. This review aims to outline BE and its relation to EAC, the rationale and cost-effectiveness of both screening and surveillance programs, methods of diagnosing and identifying dysplasia and early cancer in Barrett's, and approaches to individualizing their endoscopic and surgical management based on best-available staging techniques.

Risk factors for Barrett's esophagus in Indian patients with gastroesophageal reflux disease

BACKGROUND AND AIMS

Barrett's esophagus (BE) is reported to be infrequent in Asians, with no data from India regarding its prevalence and risk factors. We investigated the frequency and risk factors of columnar mucosa with or without specialized intestinal metaplasia (SIM) in Indian patients with gastroesophageal reflux disease (GERD).

METHODS

A total of 278 GERD patients over 2 years underwent gastroscopy and completed a questionnaire for possible BE risk factors. Patients with columnar mucosa on endoscopy underwent four-quadrant biopsy; BE was histologically defined as columnar mucosa with or without SIM. Patients without columnar mucosa at endoscopy were considered as controls and compared to patients with BE and those with SIM.

RESULTS

Forty-six patients with GERD had columnar mucosa on histology (16.54%); 25 (8.99%) of these had SIM. The risk factors for BE were the presence of hiatus hernia (odds ratio [OR]: 3.14; 95% confidence interval [CI]: 1.2-8.17) and a history of eructation (OR: 2.28; CI: 1.11-4.66). The risk factors for SIM were age ≥ 45 years (OR: 2.63; CI: 1.03-6.71), hiatus hernia (OR: 3.95; CI: 1.24-12.56), and a history of eructation (OR: 3.41; CI: 1.19-9.78). Sex, severity of symptoms, dietary factors, tobacco or alcohol use, and body mass index were not associated with BE. The median circumferential segment length was 2 (1-10) cm, and the maximal length was 3 (2-11) cm in both groups.

CONCLUSION

BE is not an uncommon finding among Indian GERD patients. Age ≥ 45 years, history of eructation, and the presence of hiatus hernia are associated with SIM.

Cancer of the gastric cardia is rising in incidence in an Asian population and is associated with adverse outcome

BACKGROUND

Tumors arising from the esophagogastric junction (OGJ) are increasing in incidence in the west, but data from Asian populations are conflicting. Singapore has a mixed-Asian population with an international lifestyle. This study was designed to examine the changing trends in incidence of gastric cardia cancer (type III) within this population and to compare the clinicopathological characteristics and outcome of these tumors with gastric tumors.

METHODS

Trends in cancer incidence were obtained from the Singapore Cancer Registry. Clinicopathological data were prospectively collected from patients undergoing surgery for gastric cancer who presented to the National University Hospital between 2000 and 2005. Patients underwent surgery with or without (neo)adjuvant therapy. Survival duration was analyzed.

RESULTS

The incidence of cardia tumors has increased each decade since 1968 (1968-1982, 6.3%; 1983-1992, 7.6%; 1993-1997, 8.4%; 1998-2002, 9.1%; 2003-2007, 16.2%). Among the study population (n = 159) cardia tumors were associated with male sex (p < 0.01) and dysphagia (p < 0.01). Although R0 resection rates were similar, systemic recurrence rates were higher among patients with cardia cancer (p = 0.031) and survival was reduced compared with patients with non-cardia gastric cancer (median survival 26 vs. 69 months; p < 0.001). Cardia location of the tumor and metastatic lymph node ratio were identified as independent adverse prognostic indicators on multivariate analysis.

CONCLUSIONS

Similar to western societies, the incidence of proximal gastric cancer is increasing in Singapore. Cardia tumors are associated with poorer outcomes, suggesting that cardia cancer is a distinct disease from true gastric cancer requiring different management strategies to improve the outcome for these patients.

From GERD to Barrett's esophagus: is the pattern in Asia mirroring that in the West?

Gastroesophageal reflux disease (GERD) is a known predisposing factor for Barrett's esophagus. Amongst individuals with symptomatic GERD, the prevalence of Barrett esophagus is estimated to be more than 10%, and an individual with Barrett's esophagus is more likely than the general population to develop esophageal adenocarcinoma. In Western Europe and North America, incidence of esophageal adenocarcinoma had been on the upward trend for many decades. In comparison, although the prevalence of GERD and reflux esophagitis has increased several fold in some parts of Asia, the prevalence of esophageal adenocarcinoma and Barrett's esophagus remains generally low in the region. Rising incidence of esophageal adenocarcinoma has been observed in regions witnessing increasing prevalence of GERD. If the recent increase in prevalence of GERD in parts of urbanized Asia is any indication of the beginning of an upsurge in the incidence of Barrett's esophagus and associated adenocarcinoma, would we be witnessing a pattern of epidemiological shift mirroring that in the West? Given that more than 90% of Barrett's esophagus in Asian patients is of the short-segment type, which is reported to have lesser propensity to develop to adenocarcinoma, could the ongoing epidemiologic transition take Asia on the same trail as that which the West has taken? This article will draw on relevant findings from various parts of Asia and take an in-depth look at prevailing disease trends to see where Asia stands now in the changing epidemiology of GERD, Barrett's esophagus and associated adenocarcinoma.

Epidemiology of symptom-defined gastroesophageal reflux disease and reflux esophagitis: the systematic investigation of gastrointestinal diseases in China (SILC)

OBJECTIVE

Gastroesophageal reflux disease (GERD) is thought to be less prevalent in China than in Western countries. However, essential population-based endoscopy data are lacking for this country.

MATERIAL AND METHODS

As part of a wider study, 3600 individuals selected randomly from the Shanghai region were asked to undergo endoscopy. Participants completed a general information questionnaire and a Chinese version of the Reflux Disease Questionnaire. When sufficient numbers were available, associations were assessed using multiple logistic regression or the Wilcoxon rank-sum test.

RESULTS

Of 3153 (87.6%) individuals who completed the survey, 1030 (32.7%) agreed to endoscopy and 1029 endoscopies were suitable for analysis. Symptom-defined GERD was more prevalent in the endoscopy group (4.7%) than in the non-endoscopy group (1.7%). Prevalence estimates were 6.4% for reflux esophagitis, 1.8% for endoscopically suspected esophageal metaplasia and 0.7% for hiatus hernia. Reflux esophagitis was more prevalent in patients with symptom-defined GERD than in those without (12.5% [6/48] vs. 6.1% [60/981]), and was significantly associated with reflux symptoms of any frequency or severity (OR = 2.10, 95% CI 1.13-3.89) and with negative Helicobacter pylori infection (OR = 0.44, 95% CI 0.25-0.80). Only 28.8% of participants with reflux esophagitis had heartburn and/or regurgitation symptoms. Epigastric burning was significantly more severe and frequent in participants with reflux esophagitis than in those without (p = 0.05).

CONCLUSIONS

Reflux esophagitis is less prevalent in China than reported in Western countries. Further work is needed to establish why reflux esophagitis appears less symptomatic in China than in Western countries.

Current status of Barrett's esophagus research in Asia

In Western countries, the epidemiology of esophageal cancer has changed considerably over the past decades with a rise in the ratio of adenocarcinoma to squamous cell carcinoma. Although the prevalence of gastroesophageal reflux is increasing in Asia, the prevalences of Barrett's esophagus (BE) and esophageal adenocarcinoma (EAC) have remained low in most Asian countries. The Asian Barrett's Consortium recently conducted a review of published studies on BE from Asia to assess the current status of BE research in Asia, and to recommend potential areas for future BE research in the region. Differences in study design, enrolled population, and endoscopic biopsy protocols used have led to substantial variability in the reported BE prevalence (0.06% to 19.9%) across Asia. In particular, some Japanese studies used diagnostic criteria that differed considerably from what was used in most Asian studies. As in Western countries, increased age, male sex, tobacco smoking, reflux symptoms, and erosive esophagitis have been found to be risk factors for BE in several case-control studies from Asia. The Prague C and M criteria, developed to provide better interobserver reliability in diagnosis and grading of BE, are currently under extensive evaluation in the Asian population. There is a need for standardized protocols for endoscopic and histopathologic diagnosis before initiating collaborative projects to identify etiologic determinants of BE and its ensuing malignant transformation. At present, data regarding the management and long-term outcome of BE are extremely limited in Asia. More studies of BE in this geographic area are warranted.

Epidemiology of gastroesophageal reflux disease in Asia: a systematic review

Ethnic and geographical differences are important factors in studying disease frequencies, because they may highlight the environmental or genetic influences in the etiology. We retrieved the studies which have been published regarding the epidemiologic features of gastroesophageal reflux disease (GERD) in Asia, based on the definitions of GERD, study settings, publication years and geographical regions. From the population-based studies, the prevalence of symptom-based GERD in Eastern Asia was found to be 2.5%-4.8% before 2005 and 5.2%-8.5% from 2005 to 2010. In Southeast and Western Asia, it was 6.3%-18.3% after 2005, which was much higher than those in Eastern Asia. There were robust epidemiologic data of endoscopic reflux esophagitis in medical check-up participants. The prevalence of endoscopic reflux esophagitis in Eastern Asia increased from 3.4%-5.0% before 2000, to 4.3%-15.7% after 2005. Although there were only limited studies, the prevalence of extra-esophageal syndromes in Asia was higher in GERD group than in controls. The prevalence of Barrett's esophagus was 0.06%-0.84% in the health check-up participants, whereas it was 0.31%-2.00% in the referral hospital settings. In summary, the prevalence of symptom-based GERD and endoscopic reflux esophagitis has increased in Asian countries. However, the prevalence of Barrett's esophagus in Asia has not changed and also still rare.

Gastroesophageal reflux disease in Asia: A historical perspective and present challenges

Gastroesophageal reflux disease (GERD), previously uncommon in Asia, has now become an important disease in the region. Although much variability exists between studies, most endoscopy-based studies show a prevalence of erosive esophagitis of more than 10%. Symptom-based studies also show a prevalence of 6-10%. Two longitudinal follow-up studies on GERD symptoms have shown an increase with time, and several endoscopy-based time trend studies have also shown a significant increase in erosive reflux esophagitis. Studies on Barrett's esophagus have been confounded by the description of short (SSBE) and long segment (LSBE) Barrett's esophagus. Great variation in prevalence rates has been reported. SSBE vary from 0.1% to more than 20% while LSBE vary from 1-2%. Of the putative causative factors, obesity has been the most important. Many studies have linked GERD-esophagitis as well as occurrence of reflux symptoms with an increase in body mass index (BMI), obesity, especially visceral or central obesity, and metabolic syndrome. A decline in Helicobacter pylori infection with growing affluence in Asia has been broadly thought to result in healthier stomachs and a higher gastric acid output resulting in reflux disease. However, variable results have been obtained from association and H. pylori eradication studies.

Epidemiology of gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD), a common disorder in Western society, is less seen in Asian countries, but there is an evidence that the incidence of GERD and its complications is rising. Many factors are believed to be responsible for the pathogenesis of GERD. In addition to some recognized factors, the role of other factors, such as obesity and Helicobacter pylori infection, in the pathogenesis of GERD is still unclear. Furthermore, GERD is believed to be associated with the development of many other diseases. This review summarizes the prevalence and risk factors of GERD and its complications.

Prevalence of Barrett's esophagus remains low in the Korean population: nationwide cross-sectional prospective multicenter study

PURPOSE

In contrast to the Western population, the prevalence of Barrett's esophagus (BE) is rare in the Korean population. However, the recent increase in prevalence of gastroesophageal reflux disease (GERD) may affect the prevalence of BE. The aim of this study was to survey the prevalence of BE and evaluate its risk factors.

METHODS

Patients between 18 and 75 years of age who visited 11 Korean tertiary referral centers between April and July 2006 for routine upper endoscopic examination were surveyed using a symptom questionnaire. Biopsies were performed on the columnar lined epithelium (CLE) of the distal esophagus, and diagnosis was confirmed with detection of specialized intestinal metaplasia.

RESULTS

The study comprised 2,048 patients (mean age 51.4 years, 965 males). The frequency of heartburn or acid regurgitation was 8.7% and 13.1%, respectively. Reflux esophagitis was diagnosed in 10.1% of patients (207 patients); however, most patients had mild reflux. CLE was found in 82 patients; however, only one patient had long-segment CLE. The prevalence of BE was 1% (21 patients). The risk factors for BE were age (P = 0.006), presence of heartburn [odds ratio (OR) 4.33, 95% confidence interval (CI) 1.66-11.34, P = 0.007], acid regurgitation (OR 3.37, 95% CI 1.35-8.42, P = 0.01), sliding hernia (OR 6.21, 95% CI 1.78-21.72, P = 0.001), and reflux esophagitis (OR 10.28, 95% CI 4.31-24.50, P < 0.0001) on univariate analysis. On multivariate analysis, presence of typical reflux symptoms (P = 0.02) and reflux esophagitis (P < 0.001) were significant.

CONCLUSIONS

Prevalence of Barrett's esophagus remains low in Koreans; however, risk of developing BE has increased in patients with GERD symptoms and reflux esophagitis.

[Diagnosis of gastroesophageal reflux disease: a systematic review]

The prevalence of gastoesophageal reflux disease (GERD) has been rapidly increased in Korea during last 20 years. However, there has been no systematic review regarding this disease. The aim of this article was to provide a review of available diagnostic modalities for GERD. This review includes proton pump inhibitor (PPI) test, endoscopy, ambulatory pH monitoring, impedance pH monitoring, and esophageal manometry in order to provide a basis for the currently applicable recommendations in the diagnosis of GERD in Korea. With weekly heartburn or acid regurgitation, the prevalence of GERD has been reported as 3.4% to 7.9%, indicating an increase of GERD in Korea. As the prevalence of Barrett's esophagus has been reported to be low, the screening endoscopy for Barrett's esophagus is not recommended. Several recent meta-analyses re-evaluated the value of the PPI test in patients with typical GERD symptoms and non-cardiac chest pain. That is, the PPI test has been proven to be a sensitive tool for diagnosing GERD in patients with non-cardiac chest pain and in some preliminary trials regarding extraesophageal manifestations of GERD. Ambulatory pH monitoring of the esophagus helps to confirm gastroesophageal reflux in patients with persistent symptoms (both typical and atypical) in the absence of esophageal mucosal damage, especially when a trial of acid suppression has failed. Impedance pH test is useful in refractory reflux patients with primary complaints of typical GERD symptoms, but this value has not been proved in patients with non-cardiac chest pain or extraesophageal symptoms. This systematic review is targeted to establish the strategy of GERD diagnosis, which is essential for the current clinical practice.

The prevalence of and risk factors for Barrett's esophagus in a Korean population: A nationwide multicenter prospective study

OBJECTIVE

The aim of this study was to evaluate the prevalence of Barrett's esophagus (BE) in the general Korean population by evaluating screening esophagogastroduodenoscopy. In addition, the risk factors for BE were identified.

METHOD

An esophagogastroduodenoscopy examination was performed in 25,536 subjects who had upper endoscopy screening from January 2006 to July 2006.

RESULTS

Two hundred and fifteen subjects were confirmed to have BE by pathology, thus the prevalence of BE was calculated to be 0.84%. The endoscopic findings were subdivided into 2 groups: BE without reflux esophagitis (RE), which included 167 (77.7%), and BE with RE, which included 48 (22.3%). The analysis of symptoms showed that only 60.1% of the subjects with BE had reflux symptoms. Chest pain [odds ratio (OR): 1.48, 95% confidence interval (CI): 1.04-2.11] and epigastric soreness (OR: 1.42, 95% CI: 1.05-1.93) were found more frequently in the subjects with BE compared with the normal subjects. The multivariate analysis showed that the risk factors for all subjects with BE were a male sex (OR: 1.82, 95% CI: 1.32-2.50), nonsteroidal anti-inflammatory drug use (OR: 2.02, 95% CI: 1.28-3.20), hiatal hernia (OR: 5.66, 95% CI: 3.70-8.66), and an age > or = 60 compared with an age < 40 (OR: 1.81, 95% CI: 1.07-3.09). There was no significant difference associated with RE.

CONCLUSIONS

The prevalence of BE in Korean patients presenting for a routine health check-up was 0.84%, lower than reported in Western countries. Among the subjects with BE 77.7% did not have endoscopic erosions and there were no reflux symptoms in 39.9%. These results suggest that regular endoscopic screening with a high index of suspicion is necessary for the diagnosis of BE.

Endoscopic definition of esophagogastric junction for diagnosis of Barrett's esophagus: importance of systematic education and training

The diagnosis of Barrett's esophagus (BE) requires an accurate recognition of the columnar-lined esophagus at endoscopy. However, a universally accepted standardized endoscopic grading system of BE was lacking prior to the development of the Prague 'circumferential and maximal' criteria. In this system, the landmark for the esophagogastric junction (EGJ) is the proximal end of the gastric folds, not the distal end of the palisade vessels, which are used to endoscopically identify the EGJ in Japan. Although the circumferential and maximal criteria are clinically relevant, an important shortcoming of this system may be failure to identify short-segment BE, a lesion that is found frequently in the Japanese. To compare the diagnostic yield for BE when using the palisade vessels versus gastric folds as a landmark for the EGJ, we evaluated interobserver diagnostic concordance. The endoscopic identification of the EGJ using both landmarks resulted in unacceptably low kappa coefficients of reliability. However, there was a statistically significant improvement after the participants were thoroughly trained in identification of the EGJ during the endoscopic study. Although it remains controversial which landmark is better for the endoscopic diagnosis of BE, it is important to systematically educate and train endoscopists in order to improve diagnostic consistency in patients with BE.

Barrett's esophagus: prevalence and risk factors in patients with chronic GERD in Upper Egypt

AIM

To determine the prevalence and possible risk factors of Barrett's esophagus (BE) in patients with chronic gastroesophageal reflux disease (GERD) in El Minya and Assuit, Upper Egypt.

METHODS

One thousand consecutive patients with chronic GERD symptoms were included in the study over 2 years. They were subjected to history taking including a questionnaire for GERD symptoms, clinical examination and upper digestive tract endoscopy. Endoscopic signs suggestive of columnar-lined esophagus (CLE) were defined as mucosal tongues or an upward shift of the squamocolumnar junction. BE was diagnosed by pathological examination when specialized intestinal metaplasia was detected histologically in suspected CLE. pH was monitored in 40 patients.

RESULTS

BE was present in 7.3% of patients with chronic GERD symptoms, with a mean age of 48.3 +/- 8.2 years, which was significantly higher than patients with GERD without BE (37.4 +/- 13.6 years). Adenocarcinoma was detected in eight cases (0.8%), six of them in BE patients. There was no significant difference between patients with BE and GERD regarding sex, smoking, alcohol consumption or symptoms of GERD. Patients with BE had significantly longer esophageal acid exposure time in the supine position, measured by pH monitoring.

CONCLUSION

The prevalence of BE in patients with GERD who were referred for endoscopy was 7.3%. BE seems to be associated with older age and more in patients with nocturnal gastroesophageal reflux.

A case of esophageal adenocarcinoma metastasized to the scalp

Cutaneous metastases from internal malignancies are, occurring in 0.5% to 9% of cases. Lung, breast, and colorectal cancers are common primary tumors that metastasize to the skin; cutaneous metastasis usually occurs on the chest wall and abdomen as asymptomatic nodular patterns. Esophageal cancer is not nearly as common as breast, lung, and colorectal cancers, and esophageal cancer rarely metastasizes to the skin. Cutaneous metastasis of esophageal cancer is rare and metastasis to the scalp is extremely rare. Only a few cases of cutaneous metastases of esophageal cancer have been reported in Korea. Most of the cases involved cutaneous metastases arising from esophageal squamous cell carcinoma; however, there have been several reports describing cutaneous metastases from esophageal adenocarcinomas. Herein, we describe a case of metastatic skin cancer that originated from esophageal adenocarcinoma.

[An evaluation of web-based information about Barrett's esophagus in Korea]

BACKGROUND/AIMS

Internet has become an important source of medical information not only for doctors but also patients. However, information available in the Internet may provide wrong or even harmful knowledge to the public. The aim of this study was to evaluate the quality of Internet-based medical information about Barrett's esophagus in Korea.

METHODS

The first 50 Internet links were retrieved from the Google using the key word Barrett's esophagus. The quality of information from a total of 49 websites was evaluated using a checklist.

RESULTS

Among total 49 sites related to Barrett's esophagus, only 4 sites (8.2%) were made by hospitals or clinics, and 11 sites (22.4%) were for patients. Of the 49 sites, only one web site (2.0%) had all HON CODE principles (authority, complementarity, confidentiality, attribution, justifiability, transparency of authorship, transparency of sponsorship, honesty in advertising and editorial policy). Sixteen Internet links (32.0%) had fair contents for the definition, and 24 links (48.0%) for the diagnosis, and 15 links (30.0%) for the treatment.

CONCLUSIONS

Information about Barrett's esophagus was incomplete in the majority of medical web sites. It will bring about confusion in patients who want to get information about Barrett's esophagus from the Internet. There is a need for better evidence-based information about Barrett's esophagus on the web.

Barrett's esophagus: where do we stand?

Barrett's esophagus (BE) is a precursor for esophageal adenocarcinoma, which has an increased incidence rate over the last few decades. Its importance stems from the poor five-year survival of esophageal adenocarcinoma and current data that suggest a survival benefit when surveillance programs are implemented. In this review, we will cover the pathophysiology and natural history of BE and the different endoscopic findings. The prevalence of BE in different geographic areas and the incidence of high-grade dysplasia and adenocarcinoma in this patient population is reviewed. Recent recommendation for screening and surveillance of BE has been covered in this review as well as the efficacy of nonconventional imaging modalities and endoscopic ablation therapies.

Gastroesophageal reflux disease: an Asian perspective

The prevalence of gastroesophageal reflux disease (GERD) ranges from 2.5% to 7.1% in most population-based studies in Asia. There is evidence that GERD and its complications are rising, coinciding with a decline in Helicobacter pylori (H. pylori) infection. Asian GERD patients share similar risk factors and pathophysiological mechanisms with their Western counterparts. Possible causes for the lower prevalence of GERD include less obesity and hiatus hernia, a lesser degree of esophageal dysmotility, a high prevalence of virulent strains of H. pylori, and low awareness. Owing to the lack of precise translation for 'heartburn' in most Asian languages, reflux symptoms are often overlooked or misinterpreted as dyspepsia or chest pain. Furthermore, a symptom-based diagnosis with a therapeutic trial of the proton pump inhibitor (PPI) may be hampered by the high prevalence of H. pylori-related disease. The risk stratification for prompt endoscopy, use of a locally-validated, diagnostic symptom questionnaire, and response to H. pylori'test and treat' help improve the accuracy of the PPI test for diagnoses. PPI remain the gold standard treatment, and 'on-demand' PPI have been shown to be a cost-effective, long-term treatment. The clinical course of GERD is benign in most patients in Asia. The risk of progression from non-erosive reflux disease to erosive esophagitis is low, and treatment response to a conventional dose of PPI is generally higher. Although H. pylori eradication may lead to more resilient GERD in a subset of patients, the benefits of H. pylori eradication outweigh the risks, especially in Asian populations with a high incidence of gastric cancer.

Low proportion of Barrett's esophagus in Asian Americans

OBJECTIVES

To determine the proportion of Barrett's esophagus (BE) in Asians versus non-Asians and the predictors of BE in patients with upper gastrointestinal (GI) symptoms.

METHODS

We performed a cross-sectional study to determine the proportion of BE from all consecutive patients who underwent esophagogastroduodenoscopy (EGD) for various indications at an outpatient, community-based gastroenterology practice in northern California from February 2000 to September 2006. BE was defined as endoscopically recognized presence of salmon-pink mucosa in the distal esophagus and intestinal metaplasia on biopsy. We also performed a nested case-control study to determine potential predictors of BE.

RESULTS

In total, 5,293 patients were reviewed. BE was more common in non-Asians (31/1464, 2.1%) than Asians (29/3829, 0.76%) (P < 0.001). In multivariate analysis controlling for increasing age, male gender, ethnicity, smoking, and alcohol, the strongest predictor of the presence of BE was non-Asian ethnicity (odds ratio [OR] 3.55, 95% confidence interval [CI] 1.85-6.85), followed by male gender (OR 2.68, 95% CI 1.32-5.45).

CONCLUSION

BE is uncommon in Asian Americans; non-Asian ethnicity and male gender are significant independent predictors of BE.

Development of Barrett's Esophagus Soon after Total Gastrectomy

The role of duodenal reflux and the time required for the development of Barrett's esophagus has remained controversial. We report a case of Barrett's esophagus that developed 6 months after total gastrectomy. A 76-year-old man diagnosed with gastric adenocarcinoma underwent a total gastrectomy and a Rouxen-Y esophagojejunostomy. The gastroesophageal junction in the resected specimen was both grossly and microscopically normal at the time of the operation. A routine follow-up endoscopic examination performed 6 months later revealed a tongue-like projection of redcolored columnar tissue. No reflux symptoms (heartburn or acid regurgitation) had been present during the intervening 6 months. A biopsy specimen from the esophagus showed intestinal-type metaplasia of the columnar epithelium. This case supports the development of Barrett's esophagus solely from duodenal reflux and after a relatively short time in this clinical setting.