Morphometric assessment of reflux oesophagitis in fibreoptic biopsy specimens

Microscopic esophagitis in gastro-esophageal reflux disease: individual lesions, biopsy sampling, and clinical correlations

Patients with non-erosive reflux disease may show microscopic damage. This study is aimed to describe distribution, sensitivity, and specificity of histological lesions (i.e., basal cell hyperplasia-BH, papillae elongation-PE, dilatation of intercellular spaces-DIS, intraepithelial eosinophils-IE, neutrophils, and erosions) and sampling criteria. Four groups were identified on the basis of symptoms, endoscopy, and pH monitoring: (1) erosive esophagitis (n = 48), (2) non-erosive esophagitis with abnormal pH (n = 59), (3) non-erosive esophagitis with normal pH (n = 12), and (4) controls (n = 20). Biopsies were taken at the Z-line and 2 and 4 cm above it. BH, PE, DIS, IE, neutrophils, and erosions were assessed. A global severity score was calculated on the basis of the above parameters and allowed the distinction of patients from controls with 80% sensitivity and 85% specificity. Lesions were more severe at Z-line than proximally and more expressed in erosive than in non-erosive disease, although more than 70% of latter patients still showed histological damage. Esophageal biopsy seems very attractive in non-erosive disease where it may contribute to diagnosis and play a role in the comparative evaluation of different therapies.

Use of MIB-1 in the assessment of esophageal biopsy specimens from patients with gastroesophageal reflux disease in well- and poorly oriented areas

MIB-1, a proliferation marker may be useful in the assessment of esophageal biopsy specimens for gastroesophageal reflux disease (GERD). Forty-five hematoxylin and eosin-stained esophageal biopsy specimens were histologically assessed for basal zone height, papillary length, and inflammatory cell infiltrate and classified as 10 normal and 35 esophagitis. The percentage of MIB-1-positive area (MIB-1% area) was measured on immunostained sections using image analysis (CAS 200) in the basal half of well-oriented areas and adjacent to five cross-sectioned papillae (c-pap) in poorly oriented areas. The cell layer of the MIB-1-positive cell furthest from the basal layer of the c-pap was also noted. MIB-1% area was significantly greater in both well- and poorly oriented areas of esophagitis biopsy specimens compared with normal biopsy specimens. MIB-1 positivity in the basal half and c-pap were correlated (r = 0.43, p = 0.017). MIB-1 expression correlated with basal zone height and eosinophil infiltrate (r = 0.61, p < 0.001; r = 0.32, p = 0.03, respectively). The cell layer with positive cells furthest from c-pap in normal and esophagitis biopsy specimens was two and six layers, respectively. Using 31% as a threshold to detect abnormal findings, the MIB-1 sensitivity/specificity and positive predictive value in the basal half and c-pap were 86, 70, 91% and 80, 80, 94%, respectively. In summary, MIB-1 staining correlates with basal zone hyperplasia and eosinophil infiltrate seen in GERD. MIB-1 staining can be assessed both in well- and poorly oriented areas as MIB-1% areas. Alternatively simply finding MIB-1 positive cells more than three cell layers from the basal layer is abnormal and consistent with GERD.

Epidermal growth factor in the oesophagus

Epidermal growth factor (EGF) has been implicated in mitogenesis and oncogenesis in the gastrointestinal tract. To determine the role of EGF in oesophageal disease, its quantity and distribution in the oesophageal mucosa of control subjects and patients with oesophageal disease were studied. Oesophageal biopsy specimens, taken 20-40 cm from the incisors in 72 patients, were graded histologically and adjacent specimens were taken for immunohistochemical analysis of the distribution of EGF. In patients with Barrett's columnar lined oesophagus, specimens were also taken from the gastric cardia for comparison. Twenty two biopsy specimens showed oesophagitis, 20 Barrett's mucosa, and 30 were histologically normal. EGF was found in the capillary endothelium of the normal oesophageal papillae and basal mucosa. Significantly more EGF positive papillae were found in the normal mucosa (81%) than in the inflamed mucosa (42%) (p < 0.001). The 20 patients with Barrett's mucosa showed abnormal expression of EGF in 25% of the isthmus and superficial epithelial cells. This study has shown that EGF is found only in the endothelial cells of the capillaries of the normal oesophageal mucosa and that the peptide is detectable significantly less frequently than normal in the inflamed oesophageal mucosa. EGF is also abnormally present, in large quantities, in the cytoplasm of the epithelial cells of Barrett's mucosa compared with gastric mucosa.

Epidermal growth factor receptors in the oesophagus

The quantity and distribution of epidermal growth factor receptors (EGF-R) in oesophageal mucosa was studied in the oesophagus in order to determine its role in oesophageal disease. Fifty five biopsies were taken from different levels of the oesophagus in 25 consecutive patients undergoing endoscopy. Another group of eight patients with histologically proven Barrett's oesophagitis had a biopsy taken from the area of columnar lined oesophagus. A peripheral, membranous pattern was seen predominantly confined to the basal and immediately suprabasal cells in all of the first group of patients. In the superficial cells a few granular cytoplasmic structures were positive. All patients with Barrett's oesophagitis showed EGF-R staining of the surface epithelium. A computerised planimeter was used to determine the proportion of stained areas of squamous cells which were expressed as a percentage of the total area of squamous cells. The difference in the area of cells stained for EGF-R between normal and inflamed oesophageal mucosa (29.5% and 43.1% respectively) was significant (p less than 0.001).

Gastroesophageal reflux disease

Gastroesophageal reflux disease, usually manifested by frequent heartburn, occurs in approximately 10% of our adult population. The presence of a hiatal hernia is usually associated with, but does not necessarily cause, LES dysfunction, allowing acid reflux to produce esophageal and aerodigestive symptoms. The mucosa can be extensively damaged and, ultimately, a columnar lining, termed Barrett's esophagus, a premalignant condition, can develop. Treatment with H2-antagonists has been nirvana to some patients, but has proved only partially helpful to others. Adjunctive agents may increase relief and may help heal erosive esophagitis in some patients, but side effects and cost limit their use. Maintenance therapy with full doses is required, as the relapse rate for this chronic condition is high. Omeprazole temporarily heals almost everyone with otherwise resistant GERD, but it is currently used only on a short-term basis unless surgery, eminently successful in well-selected patients, is contraindicated.

Assessment of oesophagitis by histology and morphometry

Morphometric measurements of nuclear area, nuclear concentration and nucleolar dimensions in defined tissue zones of orientated oesophageal biopsy sections were compared between three patient groups--asymptomatic/normal endoscopy (n = 8); symptomatic reflux/normal endoscopy (n = 17); and symptomatic/endoscopic oesophagitis (n = 15). No significant differences could be shown for any mean parameter between clinical groups. In a further group of 16 patients, identical morphometric measurements were made in non-orientated grasp biopsies and correlated with prolonged ambulatory pH data. No significant correlations could be shown between nuclear parameters and acid reflux measurements. These results suggest that morphometric measurement cannot be recommended as a diagnostic tool in the diagnosis of oesophagitis, although it may be useful in the assessment of individual therapeutic response in clinical trials.

A morphometric method to discriminate normal from dysplastic/carcinoma in situ squamous epithelium in the human esophagus

The possibility to differentiate normal squamous epithelium from dysplastic/cis in the human esophagus by means of quantitative morphometry was investigated in surgical specimens from 31 consecutive patients. The epithelium was divided into three equal zones, and a total of 186 areas was investigated. Of all variables employed, the interzonal variation between the three epithelial layers was the one showing the highest degree of efficiency (95%) in discriminating normal esophageal epithelium from dysplastic/cis lesions. Nuclear density, nuclear area, nuclear irregularity, nuclear parallelity and nuclear ovality were the most efficient discriminatory individual morphological variables. A 100% sensitivity in discriminating normal squamous epithelium from dysplastic/cis through morphometric evaluation was achieved by considering nuclear area in the superficial zone, nuclear perpendiculairty in the intermediate zone, nuclear density in the total epithelial thickness and interzonal variation of these variables. On the other hand, the specificity in discriminating dysplasia/cis lesions from normal squamous epithelium was only 96.8%. This was due to the fact that one case, by visual impression considered as dysplasia, was morphometrically recorded as normal. The view of that case showed that our initial visual impression of a dysplastic lesion proved to be erroneous, and today that case would be recorded as a reactive lesion due to chronic inflammation.

The esophagus as a source of non-cardiac chest pain

Many patients present with chest pain and are subsequently found to have normal coronary angiography; investigation of these patients frequently stops once coronary artery disease has been ruled out. It is now clear that considerable morbidity may be associated with failure to make a definite diagnosis in these patients, and that efforts to identify a cause for the pain should continue within appropriate limits. This paper presents the evidence in support of an esophageal cause of non-cardiac angina. The authors emphasize the difficulty in distinguishing between cardiac and esophageal angina on the basis of clinical history and suggest an approach to investigation.

Morphometrical analysis in ulcerative colitis with dysplasia and carcinoma

Semi-automatic image analysis was used to assess the epithelium in ulcerative colitis with dysplasia and carcinoma. There were three main sources of variation within the dataset: (1) nuclear size, nuclear cytoplasmic ratio and nuclear stratification; (2) the variation of nuclear size; and (3) nuclear shape and polarity. Discriminant analysis chose the mean nuclear cytoplasmic ratio % and the coefficient of variation of nucleus to cell apex distance to derive a scoring system which completely separated normal mucosa (n = 20) and carcinoma (n = 30). The classification rule allocated all high grade dysplasia to the tumour category. Scores for regeneration and low grade dysplasia overlapped with each other and the normal and tumour groups. Scatter plots of the two discriminating variables showed good separation of regeneration and high grade dysplasia, and a degree of overlap with low grade dysplasia. The scatter plots allowed identification of overlapping and misallocated cases, requiring review of their histology and redesignation of the diagnosis in five cases. This study confirms quantitatively the visual criteria used in grading mucosal changes and their trend from regeneration through dysplasia to carcinoma. It underlines the necessity of assessing not only cytological but also architectural and inflammatory components when diagnosing regeneration and low grade dysplasia. Mucosal morphometry may be of use in confirming high grade dysplasia which is an indication for colectomy.

Oesophageal histology in reflux oesophagitis

Multiple specimens taken at oesophageal suction biopsy were obtained from 56 patients, of whom 44 had symptoms of gastro-oesophageal reflux and 24 had endoscopic evidence of erosive oesophagitis. Biopsies were examined independently by two histopathologists for the following criteria for reflux: epithelial hyperplasia, vascular dilatation and congestion, neutrophil infiltration, and eosinophil infiltration. The incidence of these criteria in patients with and without endoscopic evidence of oesophagitis or symptoms of reflux was investigated. It was concluded that vascular dilatation and epithelial hyperplasia, defined as basal zone thickness greater than or equal to 15% and papillary elongation greater than or equal to 66%, can be detected most reliably, but their diagnostic accuracy is limited unless multiple biopsies are examined.