The prevalence of intestinal metaplasia in patients with and without peptic strictures

Precision care for Barrett's esophagus

Modern recognition and management of Barrett's esophagus, a precursor to esophageal adenocarcinoma depends on diagnostic accuracy, risk assessment, technical expertise and consideration of many options to best tailor therapy for every patient. Concomitant management of acid reflux is essential, frequently with proton pump inhibitors. Ablation and resection favorably affect the evolution towards cancer. Using precision medicine tools, such as imaging, molecular diagnostics and analytics may lead to cost- and comparatively-effective therapies ultimately aiming at cancer prevention. Knowledge of the risk factors for Barrett's esophagus and progression to dysplasia and cancer can help tailor a precision medicine approach with more aggressive screening and surveillance targeted at patients that are most likely to benefit.

Screening for Barrett's esophagus in asymptomatic women

BACKGROUND

Barrett's esophagus (BE) has been detected in approximately 10% of patients with chronic GERD. Previous studies demonstrated a similar prevalence of BE in asymptomatic adults.

OBJECTIVE

To determine the prevalence of BE in asymptomatic women.

DESIGN

We invited women scheduled for routine screening colonoscopy (for colorectal cancer) and women undergoing endoscopic examination before bariatric surgery to participate. Patients experiencing heartburn symptoms more than once per month were excluded.

SETTING

Outpatients at Stanford University and Palo Alto VA Health Care System.

INTERVENTIONS

Biopsies of the esophagogastric junction in the setting of suspected BE, and completion of symptom and health-related quality of life questionnaires to ensure that subjects were asymptomatic.

MAIN OUTCOME MEASUREMENT

Identification of BE.

RESULTS

We detected BE in 8 (6%) of 126 subjects, including 3 (5%) of 61 of the women in the colorectal cancer screening cohort and 5 (8%) of 65 of the women in the pre-bariatric surgery cohort, all of whom had BE measuring 2 cm or less (P = .30). Patients found to have BE were more likely to be older (mean age 60 years vs 49 years, respectively; P = .04), but there was no difference in mean body mass index, ethnicity, or tobacco or alcohol use between patients with and without BE. BE was only present in pre-bariatric surgery subjects younger than the age of 50 and was most common in the 61- to 70-year age cohort in both groups. Erosive esophagitis, microscopic reflux changes, and Helicobacter pylori infection were not more common in the pre-bariatric surgery group.

LIMITATION

Small number of subjects with BE detected.

CONCLUSIONS

Short-segment BE was detected in 6% of asymptomatic women undergoing screening endoscopic examinations.

Peptic esophageal stricture: a report from Argentina

Peptic esophageal stricture (PES) is a major complication of gastroesophageal reflux disease. The aims of this paper were to determine the characteristics of these patients with regard to demography, morphology, functional status and results of therapy. The charts of the patients treated at our service who underwent esophageal dilatation for PES between 1971 and 1998 were reviewed. Statistical analyses were performed by means of chi2, Mann-Whitney and Student's t-tests. One hundred and thirty-five patients with PES were dilated by various means. The mean age was 61.1 +/- 16.3 years, the ratio of men to women was 2.75/1 and mean duration of symptoms was 44.4 +/- 74.6 months. Their symptoms were dysphagia in 100%, pyrosis in 70%, and regurgitation in 40% of the cases. There was an average weight loss of 3.3 +/- 6 kg. The upper gastro-intestinal series showed pre- and post-dilatation diameters at the stricture of 8 +/- 2.5 mm and 15.9 +/- 1.2 mm, respectively. The stricture was located at the lower third of the esophagus in 97% and at the middle third in 3% of the cases. We found PES endoscopically in all instances, with different degrees of erosions in 64%, ulcers in 20% and Barrett's esophagus in 16% of the cases. The biopsy samples showed intestinal metaplasia in 16% and esophagitis in 75.5%, being normal in the remaining 8.5%. Brush cytology was negative for malignancy in 100% of the cases. Esophageal manometry showed peristaltic wave amplitude of 40 +/- 3 mmHg and presence of peristaltic waves of 62 +/- 38.6%. LES pressure was 8.6 +/- 6.3 mmHg (NV 24.2 +/- 6.3 mmHg). Measurement of pH showed 15% of patients had pH < 4. Patients needed a mean of 4.7 +/- 1.6 dilations per case, with successful results in 87.2% of cases. The perforation rate was 0.1% of the total number of procedures and 0.7%, of patients. The mortality rate was 0.7% (one case). We observed PES relapse in 32% of the cases. There was no correlation between relapse, age, duration of the stenosis or pharmacological treatment with H2 blockers or proton pump inhibitors. We conclude that in Argentina, demography, morphology, functional status and results of dilatation of PES patients are similar to those reported in the Western world, with the exception of the different behavior seen after treatment with H2 blockers or proton pump inhibitors.

Barrett's esophagus

Barrett's esophagus is an acquired condition resulting from severe esophageal mucosal injury. It still remains unclear why some patients with gastroesophageal reflux disease develop Barrett's esophagus whereas others do not. The diagnosis of Barrett's esophagus is established if the squamocolumnar junction is displaced proximal to the gastroesophageal junction and if intestinal metaplasia is detected by biopsy. Despite this seemingly simple definition, diagnostic inconsistencies remain a problem, especially in distinguishing short segment Barrett's esophagus from intestinal metaplasia of the gastric cardia. Barrett's esophagus would be of little importance were it not for its well-recognized association with adenocarcinoma of the esophagus. The incidence of esophageal adenocarcinoma continues to increase and the 5-year survival rate for this cancer remains dismal. However, cancer risk for a given patient with Barrett's esophagus is lower than previously estimated. Current strategies for improved survival in patients with esophageal adenocarcinoma focus on cancer detection at an early and potentially curable stage. This can be accomplished either by screening more patients for Barrett's esophagus or with endoscopic surveillance of patients with known Barrett's esophagus. Current screening and surveillance strategies are inherently expensive and inefficient. New techniques to improve the efficiency of cancer surveillance are evolving rapidly and hold the promise to change clinical practice in the future. Treatment options include aggressive acid suppression, antireflux surgery, chemoprevention, and ablation therapy, but there is still no clear consensus on the optimal treatment for these patients.

Peptic strictures of the esophagus

Peptic esophageal strictures occur in the context of inadequately treated gastroesophageal reflux, especially in elderly patients. Studies show more pronounced abnormalities of esophageal function resulting in an increased number of prolonged reflux episodes. The diagnosis is best made by a combination of barium esophagram and endoscopy. Patients usually require esophageal dilation to relieve dysphagia followed by adequate medical therapy. Proton pump inhibitors are effective for preventing the recurrence of strictures after dilation. In young patients and patients with strictures that are difficult to dilate or need frequent dilations, surgery may be required; however, results can be disappointing.