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

Association of Physicians of India Consensus Recommendations for Vonoprazan in Management of Acid Peptic Disorders

The suppression of gastric acid secretion has long been the cornerstone of treatment for acid peptic disorders (APDs). Proton pump inhibitors (PPIs) have played a central role in managing these conditions, but their effectiveness can be hindered by notable limitations such as refractoriness or treatment failure due to inadequate acid suppression in some gastroesophageal reflux disease (GERD) patients, nonadherence to prescribed regimens due to the complexity of dosing, variability of response, and nocturnal acid breakthrough, etc. Vonoprazan is a first-in-class potassium-competitive acid blocker (P-CAB), recently introduced in India and also approved in several countries such as Japan, South Korea, and the USA. Extensive clinical evidence suggests that vonoprazan offers more potent acid suppression than PPIs. This consensus from the Association of Physicians of India (API) has been developed with the objective of providing key recommendations for the appropriate clinical usage of vonoprazan across various subsets of APDs, thereby optimizing the existing therapeutic options and improving the care and management of APD patients.

Association between hiatal hernia and Barrett's esophagus: an updated meta-analysis with trial sequential analysis

BACKGROUND

Barrett's esophagus (BE) is a precursor of esophageal adenocarcinoma. It is critical to recognize the risk factors associated with BE.

OBJECTIVES

The present meta-analysis aims to systematically estimate the association of hiatal hernia with the risk of BE.

DESIGN

A meta-analysis with trial sequential analysis.

DATA SOURCES AND METHODS

The PubMed, EMBASE, and Cochrane Library databases were searched. The pooled odds ratios (ORs) and adjusted ORs (aORs) with their 95% confidence intervals (CIs) were calculated for the combined estimation of unadjusted data and data adjusted for confounders, respectively. Heterogeneity was quantified using the Cochrane Q test and I² statistics. Subgroup, meta-regression, and leave-one-out sensitivity analyses were employed to explore the sources of heterogeneity.

RESULTS

Forty-seven studies with 131,517 participants were included. Based on the unadjusted data from 47 studies, hiatal hernia was significantly associated with an increased risk of any length BE (OR = 3.91, 95% CI = 3.31-4.62, p < 0.001). The heterogeneity was significant (I² = 77%; p < 0.001) and the definition of controls (p = 0.014) might be a potential contributor to heterogeneity. Based on the adjusted data from 14 studies, this positive association remained (aOR = 3.26, 95% CI = 2.44-4.35, p < 0.001). The heterogeneity was also significant (I² = 65%; p < 0.001). Meta-analysis of seven studies demonstrated that hiatal hernia was significantly associated with an increased risk of long-segment BE (LSBE) (OR = 10.01, 95% CI = 4.16-24.06, p < 0.001). The heterogeneity was significant (I² = 78%; p < 0.001). Meta-analysis of seven studies also demonstrated that hiatal hernia was significantly associated with an increased risk of short-segment BE (OR = 2.76, 95% CI = 2.05-3.71, p < 0.001). The heterogeneity was not significant (I² = 30%; p = 0.201).

CONCLUSION

Hiatal hernia should be a significant risk factor for BE, especially LSBE.

REGISTRATION

PROSPERO registration number CRD42022367376.

Global variations in diagnostic guidelines for Barrett's esophagus

Endoscopic diagnosis of gastroesophageal junction and Barrett's esophagus is essential for surveillance and early detection of esophageal adenocarcinoma and esophagogastric junction cancer. Despite its small size, the gastroesophageal junction has many inherent problems, including marked differences in diagnostic methods for Barrett's esophagus in international guidelines. To define Barrett's esophagus, gastroesophageal junction location should be clarified. Although gastric folds and palisade vessels are landmarks for identifying this junction, they are sometimes difficult to observe due to air entry or reflux esophagitis. The possibility of diagnosing a malignancy associated with Barrett's esophagus <1 cm, identified using palisade vessels, should be re-examined. Nontargeted biopsies of Barrett's esophagus are commonly used to detect intestinal metaplasia, dysplasia, and cancer as described in the Seattle protocol. Barrett's esophagus with intestinal metaplasia has a high risk of becoming cancerous. Furthermore, the frequency of cancer in patients with Barrett's esophagus without intestinal metaplasia is high, and the guidelines differ on whether to include the presence of intestinal metaplasia in the diagnosis of Barrett's esophagus. Use of advanced imaging technologies, including narrow-band imaging with magnifying endoscopy and linked color imaging, is reportedly valid for diagnosing Barrett's esophagus. Furthermore, artificial intelligence has facilitated the diagnosis of Barrett's esophagus through its deep learning and image recognition capabilities. However, it is necessary to first use the endoscopic definition of the gastroesophageal junction, which is common in all countries, and then elucidate the characteristics of Barrett's esophagus in each region, for example, length differences in the risk of carcinogenesis with and without intestinal metaplasia.

Gender differences in Barrett's esophagus and progression of disease: a systematic review and meta-analysis

It is known that Barrett's esophagus (BE) and esophageal adenocarcinoma occur more commonly in men. What is unknown are the prevalence of BE and rates of neoplastic progression in women. Our aim was to determine the prevalence of Barrett's and its progression to esophageal cancer in women through systematic review and meta-analysis. A comprehensive search was conducted using PubMed, Scopus, and Google Scholar. Studies were included that reported prevalence rates of BE or progression rates to neoplastic disease stratified by gender. Barrett's was defined by updated criteria as salmon-colored mucosa ≥1 cm proximal to the gastroesophageal junction. Pooled rates and odds ratios (ORs) at 95% confidence interval (CI) of the prevalence of BE and its progression to neoplastic disease were calculated. Ten studies with 19,337 patients (50.6% women) reported on prevalence and six studies with 5137 patients (24.3% women) reported on neoplastic progression of disease between genders. The rate of BE in women was 1.29% ([95% CI: 0.76-2.19], I2 = 91%) compared to men at 4.66% ([95% CI: 3.31-6.53], I2 = 89%); OR: 0.33 ([95% CI: 0.27-0.42], I2 = 0%). The rate of annual progression of Barrett's to high-grade dysplasia or adenocarcinoma was 0.62% ([95% CI: 0.22-1.75]) in women compared to 1.54% ([95% CI: 0.83-2.81], I2 = 96%) in men; OR: 0.44 ([95% CI: 0.30-0.65], I2 = 22%). This study demonstrates a 70% lower rate of prevalence and a 60% lower rate of neoplastic progression of Barrett's in women. Future BE guidelines should tailor screening and surveillance practices by gender.

Are we Missing Barrett's Esophagus in Our Busy Endoscopy Practice? Improving Detection

Barrett's esophagus (BE) denotes the replacement of stratified squamous epithelium of esophagus by columnar epithelium. It is associated with a significantly increased risk of esophageal adenocarcinoma and hence patients with BE are advised endoscopic surveillance for early detection of dysplastic and neoplastic lesions. Esophageal cancer is the sixth most common cancer in terms of incidence and mortality in India. Around 15 to 25% of esophageal cancers are adenocarcinoma. BE is likely to be an important precursor of esophageal adenocarcinoma and we may be missing patients with BE in our busy endoscopy practice. The detection of BE may be improved by identifying high-risk groups, performing thorough endoscopic examination, and applying newer imaging techniques. The high-risk group includes patients with chronic gastroesophageal reflux disease, obesity, smoking, etc. During endoscopic examination, a careful assessment of the gastroesophageal junction and identification of important landmarks such as gastroesophageal junction and Z line are essential to detect BE. Management of BE depends on the detection of dysplasia and for this four quadrant mucosal biopsy is recommended every 1 to 2 cm. However, random biopsy samples only a small area of mucosa and advanced technologies for real-time detection of dysplasia and neoplasia may overcome this limitation. In this review, we discuss the current scenario of BE in India and ways to improve the detection of BE including dysplastic lesions.

Lifestyle interventions can reduce the risk of Barrett's esophagus: a systematic review and meta-analysis of 62 studies involving 250,157 participants

Background

Barrett's esophagus (BE) is a well‐established risk factor for esophageal adenocarcinoma. Our objective was to investigate the effectiveness of lifestyle interventions on BE risk.

Methods

We searched PubMed, Embase, and Web of Science up to 30 September 2020. The summary relative risks (RRs) and 95% confidence intervals (CIs) for the highest versus lowest categories of exposure were assessed. Analyses of subgroup, dose–response, sensitivity, and publication bias were conducted.

Results

Sixty‐two studies were included that involved more than 250,157 participants and 22,608 cases. Seven lifestyle factors were investigated: smoking, alcohol, body mass index (BMI), physical activity, sleep time, medication, and diet. We observed statistically significant increased BE risks for smoking (RR = 1.35, 95% CI = 1.16–1.57), alcohol intake (RR = 1.23, 95% CI = 1.13–1.34), body fatness (RR = 1.08, 95% CI = 1.03–1.13), less sleep time (RR = 1.76, 95% CI = 1.24–2.49), and proton pump inhibitors use (RR = 1.64, 95% CI = 1.17–2.29). Reduced risks of BE were found for aspirin (RR = 0.70, 95% CI = 0.58–0.84) and the intake of vitamin C (RR = 0.59, 95% CI = 0.44–0.80), folate (RR = 0.47, 95% CI = 0.31–0.71), and fiber (RR = 0.95, 95% CI = 0.93–0.97). The quality of most included studies was high and the subgroup analysis according to the quality score showed significant results (p < 0.05). There was no publication bias for smoking and alcohol. Although the analysis suggested significant evidence of publication bias for BMI, sensitivity analysis showed that the changes in the recalculated RRs were not significant.

Conclusions

The large meta‐analysis revealed that lifestyle modifications could reduce the risks of BE and, consequently, esophageal adenocarcinoma.

Systematic review with meta-analysis: risk factors for Barrett's oesophagus in individuals with gastro-oesophageal reflux symptoms

BACKGROUND

Gastro-oesophageal reflux is considered the main risk factor for Barrett's oesophagus. The role of other potential risk factors for the development of Barrett's oesophagus in patients with gastro-oesophageal reflux symptoms is controversial.

AIMS

To perform a systematic review and meta-analysis examining risk factors in development of Barrett's oesophagus.

METHODS

Medline, Embase and Embase Classic were searched (until December 2020) to identify cross-sectional studies reporting prevalence of Barrett's oesophagus based on presence of one or more proposed risk factors in individuals with gastro-oesophageal reflux symptoms. Prevalence of Barrett's oesophagus was compared according to presence or absence of each risk factor in individuals with gastro-oesophageal reflux symptoms.

RESULTS

Of 7164 citations evaluated, 13 studies reported prevalence of Barrett's oesophagus in 11 856 subjects. Pooled prevalence of histologically confirmed Barrett's oesophagus in individuals with gastro-oesophageal reflux symptoms in all studies was 7.0% (95% CI 4.8% to 9.6%). Prevalence was higher in subjects with hiatal hernia (OR 2.74; 95% CI 1.58 to 4.75) and in those who drank alcohol (OR 1.51; 95% CI 1.17 to 1.95). Other features including non-steroidal anti-inflammatory drugs and/or aspirin use (OR 1.19; 95% CI 1.00 to 1.42), smoking (OR 1.14; 95% CI 0.96 to 1.35) or obesity (OR 1.10; 95% CI 0.92 to 1.33) were not significantly associated with Barrett's oesophagus.

CONCLUSIONS

The prevalence of Barrett's oesophagus in individuals with gastro-oesophageal reflux symptoms was higher in those who drank alcohol, although this association was modest. The strongest association found was between hiatal hernia and Barrett's oesophagus. Other potential risk factors assessed in this study did not appear to be associated with presence of Barrett's oesophagus among individuals with gastro-oesophageal symptoms.

Global prevalence of Barrett's oesophagus and oesophageal cancer in individuals with gastro-oesophageal reflux: a systematic review and meta-analysis

OBJECTIVES

Chronic gastro-oesophageal reflux might lead to the development of Barrett's oesophagus (BO) or even oesophageal adenocarcinoma. There has been no definitive systematic review and meta-analysis of data to estimate global prevalence of BO or oesophageal adenocarcinoma in individuals with gastro-oesophageal reflux.

DESIGN

We searched MEDLINE, Embase and Embase Classic to identify cross-sectional surveys that reported prevalence of BO or oesophageal adenocarcinoma in adults with gastro-oesophageal reflux. We extracted prevalence for all studies, both for endoscopically suspected and histologically confirmed cases. We calculated pooled prevalence according to study location, symptom frequency and sex, as well as ORs with 95% CIs.

RESULTS

Of the 4963 citations evaluated, 44 reported prevalence of endoscopically suspected and/or histologically confirmed BO. Prevalence of BO among individuals with gastro-oesophageal reflux varied according to different geographical regions ranging from 3% to 14% for histologically confirmed BO with a pooled prevalence of 7.2% (95% CI 5.4% to 9.3%), whereas pooled prevalence for endoscopically suspected BO was 12.0% (95% CI 5.5% to 20.3%). There was heterogeneity in many of our analyses. Prevalence of BO was significantly higher in men, both for endoscopically suspected (OR=2.1; 95% CI 1.6 to 2.8) and histologically confirmed BO (OR=2.3; 95% CI 1.7 to 3.2). Dysplasia was present in 13.9% (95% CI 8.9% to 19.8%) of cases of histologically confirmed BO, 80.7% of which was low-grade.

CONCLUSION

The prevalence of Barrett's oesophagus among individuals with gastro-oesophageal reflux varied strikingly among countries, broadly resembling the geographical distribution of gastro-oesophageal reflux itself. Prevalence of BO was significantly higher in men.

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.

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.

Indian consensus on gastroesophageal reflux disease in adults: A position statement of the Indian Society of Gastroenterology

The Indian Society of Gastroenterology developed this evidence-based practice guideline for management of gastroesophageal reflux disease (GERD) in adults. A modified Delphi process was used to develop this consensus containing 58 statements, which were generated by electronic voting iteration as well as face-to-face meeting and review of the supporting literature primarily from India. These statements include 10 on epidemiology, 8 on clinical presentation, 10 on investigations, 23 on treatment (including medical, endoscopic, and surgical modalities), and 7 on complications of GERD. When the proportion of those who voted either to accept completely or with minor reservation was 80% or higher, the statement was regarded as accepted. The prevalence of GERD in India ranges from 7.6% to 30%, being  < 10% in most population studies, and higher in cohort studies. The dietary factors associated with GERD include use of spices and non-vegetarian food. Helicobacter pylori is thought to have a negative relation with GERD; H. pylori negative patients have higher grade of symptoms of GERD and esophagitis. Less than 10% of GERD patients in India have erosive esophagitis. In patients with occasional or mild symptoms, antacids and histamine H2 receptor blockers (H2RAs) may be used, and proton pump inhibitors (PPI) should be used in patients with frequent or severe symptoms. Prokinetics have limited proven role in management of GERD.

Central Obesity and H. pylori Infection Influence Risk of Barrett's Esophagus in an Asian Population

Background and Aim

The prevalence rates of Barrett’s esophagus (BE) in western countries are higher than Asian ones, but little is known about their difference among risk factors of BE. The aim of this study is to investigate the associations of various risk factors including central obesity, body mass index (BMI), metabolic syndrome and H. pylori infection, with BE.

Methods

A total of 161 subjects with BE were enrolled and compared to age- and gender-matched controls randomly sampled (1:4) from check-up center in same hospital. Central obesity was defined by waist circumference (female>80cm; male>90cm), metabolic syndrome by the modified National Cholesterol Education Program Adult Treatment Panel III criteria in Taiwan. Independent risk factors for BE were identified by multiple logistic regression analyses.

Results

The mean age for BE was 53.8±13.7 years and 75.8% was male. H. pylori infection status was detected by the rapid urease test with the prevalence of 28.4% and 44.4% in the BE patients and controls, respectively. The univariate logistic regression analyses showed the risk was associated with higher waist circumference (odds ratio [OR], 2.53; 95% confidence interval [CI], 1.78–3.60), metabolic syndrome (OR, 2.02; 95% CI, 1.38–2.96) and negative H. pylori infection (OR, 0.50; 95% CI, 0.34–0.74). However, multivariate logistic regression analyses revealed that BE associated with higher waist circumference (adjusted OR, 2.79; 95% CI, 1.89–4.12) and negative H. pylori infection (adjusted OR, 0.46; 95% CI, 0.30–0.70).

Conclusions

Central obesity is associated with a higher risk of BE whereas H. pylori infection with a lower risk in an ethnic Chinese population.

Asia-Pacific consensus on the management of gastro-oesophageal reflux disease: an update focusing on refractory reflux disease and Barrett's oesophagus

OBJECTIVE

Since the publication of the Asia-Pacific consensus on gastro-oesophageal reflux disease in 2008, there has been further scientific advancement in this field. This updated consensus focuses on proton pump inhibitor-refractory reflux disease and Barrett's oesophagus.

METHODS

A steering committee identified three areas to address: (1) burden of disease and diagnosis of reflux disease; (2) proton pump inhibitor-refractory reflux disease; (3) Barrett's oesophagus. Three working groups formulated draft statements with supporting evidence. Discussions were done via email before a final face-to-face discussion. We used a Delphi consensus process, with a 70% agreement threshold, using Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria to categorise the quality of evidence and strength of recommendations.

RESULTS

A total of 32 statements were proposed and 31 were accepted by consensus. A rise in the prevalence rates of gastro-oesophageal reflux disease in Asia was noted, with the majority being non-erosive reflux disease. Overweight and obesity contributed to the rise. Proton pump inhibitor-refractory reflux disease was recognised to be common. A distinction was made between refractory symptoms and refractory reflux disease, with clarification of the roles of endoscopy and functional testing summarised in two algorithms. The definition of Barrett's oesophagus was revised such that a minimum length of 1 cm was required and the presence of intestinal metaplasia no longer necessary. We recommended the use of standardised endoscopic reporting and advocated endoscopic therapy for confirmed dysplasia and early cancer.

CONCLUSIONS

These guidelines standardise the management of patients with refractory gastro-oesophageal reflux disease and Barrett's oesophagus in the Asia-Pacific region.

Risk factors for Barrett's esophagus: a scoping review

INTRODUCTION

Cancer of the esophagus is a highly lethal disease with many patients presenting with metastatic spread of their tumor at diagnosis; a consequence of this late presentation is the 5-year survival rate of <20 %. Barrett's esophagus (BE), a premalignant condition of the distal esophagus, is the main risk factor for adenocarcinoma of the esophagus. The development of a risk prediction tool that could assist healthcare professionals in identifying people at increased risk of developing BE would be advantageous. Understanding the factors that influence the risk of developing BE is the first stage of developing a risk prediction tool.

METHODS

A scoping review was undertaken to address the following question 'what factors influence the risk of developing Barrett's esophagus?' Forty-six articles were included in this review.

RESULTS

The majority of articles reviewed were case-control or cohort studies. Samples sizes ranged from 68 to 84,606. Risk factors reported to be statistically significant were divided into three categories: demographic, lifestyle and clinical factors. Strongest risk factors identified include: male gender, increasing age, white race, smoking, obesity and gastro-esophageal reflux disease symptoms, while some aspects of a person's diet appear to act as a protective measure.

CONCLUSION

Risk factors for BE are complex and need to be considered by healthcare professionals when identifying patients that could benefit from endoscopic eradication. These results provide a stepping stone for the future development of a risk prediction model.

Peptic esophageal stricture in an adolescent with Barrett's esophagus

Barrett's esophagus (BE) is characterized by the replacement of distal esophageal stratified squamous epithelium by columnar epithelium. It is rare in children and the risk factors may include mental retardation, cerebral palsy, esophageal atresia, etc. Apart from corrosive ingestion, peptic stricture is the other leading cause of esophageal strictures in children. However, BE has not been well characterized in the pediatric population and in children presenting with esophageal strictures. A 16-year-old Indian boy presented with a history of gradually progressive dysphagia to solids (but not liquids) for 12 years along with heartburn and poor weight gain. Physical examination and routine blood investigations were unremarkable. Previously performed barium meal studies were suggestive of stricture in the mid and lower esophagus. Upper gastrointestinal (GI) endoscopy revealed a non-negotiable stricture with circumferential ulceration at 26 cm. The stricture was traversed using an ultrathin scope and the distal mucosa was found to be columnar. Biopsies revealed cardiac mucosa. The patient was treated with proton pump inhibitors (PPI) and four series of segmental dilatations with Savary Gilliard esophageal dilators. Peptic strictures occurring in the mid-upper esophagus should raise concerns about BE or malignancy. Here, we report a case of peptic esophageal stricture in a child without neurodevelopmental or trachea-esophageal abnormalities.

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.

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.

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.

Hiatal hernia and the risk of Barrett's esophagus

BACKGROUND AND AIM

Barrett's esophagus has been associated with the presence of hiatal hernia; however, to date no meta-analysis of the relationship has been performed. We aimed to conduct a systematic review and meta-analysis, providing a quantitative estimate of the increased risk of Barrett's esophagus associated with hiatal hernia.

METHODS

A search was conducted through four electronic databases (Medline, PubMed, Embase, and Current Contents Connect) to 4 April 2012, for observational studies of Barrett's esophagus patients. We calculated pooled odds ratios and 95% confidence intervals using a random effects model for the association of hiatal hernia with any length Barrett's esophagus, as well as with short segment Barrett's esophagus and long segment Barrett's esophagus. 33 studies comprising 4390 Barrett's esophagus patients were eligible for the meta-analysis.

RESULTS

Hiatal hernia was associated with an increased risk of Barrett's esophagus of any length (odds ratio 3.94; 95% confidence interval 3.02-5.13). Heterogeneity was present (I2 = 82.03%, P < 0.001), and the Egger test for publication bias was significant (P = 0.0005). The short segment Barrett's esophagus subgroup analysis likewise showed an increased risk (odds ratio 2.87; 95% confidence interval 1.75-4.70). The strongest association was between hiatal hernia and long segment Barrett's esophagus (odds ratio 12.67; 95% confidence interval 8.33-19.25). The increased risk was present even after adjusting for reflux and body mass index.

CONCLUSIONS

 The presence of hiatal hernia was associated with an increased risk of Barrett's esophagus, even after adjusting for clinically significant confounders. The strongest association was found between hiatal hernia and long segment Barrett's esophagus.

Endoscopic submucosal dissection -- initial experience from India: a case series of five patients

Endoscopic submucosal dissection (ESD) is an established modality of treatment of mucosal and submucosal tumors (SMTs) of the gastrointestinal (GI) tract. Although the technique is established in the eastern countries, currently there are no reports of this technique from India. We present here our initial experience of 5 patients with mucosal or SMTs at various locations in the GI tract treated by ESD. The criteria for patient selection, technical challenges encountered during the procedure and future directions for ESD development in India are discussed.

Reflux and sex: what drives testing, what drives treatment?

Gastroesophageal reflux (GER) affects ∼10-20% of American adults. Although symptoms are equally common in men and women, we hypothesized that sex influences diagnostic and therapeutic approaches in patients with GER. PubMed database between 1997 and October 2011 was searched for English language studies describing symptoms, consultative visits, endoscopic findings, use and results of ambulatory pH study, and surgical therapy for GER. Using data from Nationwide Inpatient Sample, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality, we determined the sex distribution for admissions and reflux surgery between 1997 and 2008. Studies on symptoms or consultative visits did not show sex-specific differences. Even though women are less likely to have esophagitis or Barrett's esophagus, endoscopic studies enrolled as many women as men, and women were more likely to undergo ambulatory pH studies with a female predominance in studies from the US. Surgical GER treatment is more commonly performed in men. However, studies from the US showed an equal sex distribution, with Nationwide Inpatient Sample data demonstrating an increase in women who accounted for 63% of the annual fundoplications in 2008. Despite less common or severe mucosal disease, women are more likely to undergo invasive diagnostic testing. In the US, women are also more likely to undergo antireflux surgery. These results suggest that healthcare-seeking behavior and socioeconomic factors rather than the biology of disease influence the clinical approaches to reflux disease.