High peptic stricture of the oesophagus

Small-bowel metaplasia arising in the remnant esophagus after esophagojejunostomy--a [corrected] prospective study in patients with a history of total gastrectomy

OBJECTIVES

The pathogenesis of Barrett's mucosa is incompletely understood. Acidic gastro-esophageal reflux is considered an essential causative factor. The aim of this study was to detect esophageal columnar metaplasia after total gastrectomy with esophagojejunostomy, a condition of enteric, but nonacidic reflux.

METHODS

In a prospective study, patients with a history of total gastrectomy and esophagojejunostomy were investigated for the presence of columnar metaplasia in the remnant esophagus. Patients with such history, who were now referred for esophagogastroduodenoscopy, were included during a 2-yr period. Biopsies for histopathology were taken from the anastomosis and any columnar metaplasia of the esophagus.

RESULTS

In 8 of 25 patients (32%) with a history of gastrectomy, columnar metaplasia was found in the remnant esophagus, mostly in shape of tongues, partly associated with erosive reflux esophagitis. Histopathology showed a typical small-bowel mucosa, but with some villous atrophy. In a resection specimen, a double-layered muscularis mucosa was present, which proved the metaplastic nature of the intestinal mucosa. Length of the columnar metaplasia correlated with the time interval since surgery.

CONCLUSIONS

Esophageal mucosa, if exposed long term to an enteric, but nongastric refluxate, can evolve into a highly differentiated intestinal metaplasia, which resembles small-bowel mucosa. This proves that complete-type intestinal metaplasia may arise not only in the stomach, but also in the esophagus. Esophageal intestinalization seems to reflect adaptation to enteric reflux.

Barrett's epithelium with complete stricture of the esophagus: hypothesis of its etiology

A 4-year-old very debilitated boy, who suffered from recurrent vomiting (regurgitation) since birth, is described. At the age of 18 months, partial obstruction of the esophagus was apparent, and only semisolid food could be swallowed. The signs of obstruction progressed, and the child was admitted urgently, at the age of 4 years, to the authors' department because of severe dehydration. After resuscitation, a barium swallow and esophagoscopy showed a complete obstruction of the esophagus between its middle and lower third. Through a left thoracotomy incision, 4 cm of the diseased esophagus were resected and continually established by end-to-end esophagoesophageal anastomosis. Pathological examination showed complete obstruction of the esophagus with Barrett's epithelium above and below the stricture. Severe periesophagitis was also present because of sealed perforation of the esophagus. One week after the operation the child was on a normal diet. On follow-up, 6 months later, he has no signs of obstruction and is gaining weight. It is postulated that the presence of Barrett's epithelium in the esophagus in congenital, but the complications, such as stricture formation, are usually caused by chronic irritation, such as gastroesophageal reflux. Barrett's epithelium alone infrequently will cause

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.

Duodenogastric reflux in patients with Barrett's esophagus

The role of duodenogastric reflux in the pathogenesis of gastroesophageal reflux disease is not clear. Using hepatobiliary scanning techniques, we found evidence of duodenogastric reflux in six of 13 patients with Barrett's esophagus. This compares with only two positive studies in 19 control subjects. This difference is statistically significant (P = 0.038, two-tailed Fisher's exact test). Three of nine patients who had gastroesophageal reflux without Barrett's esophagus had evidence of duodenogastric reflux, a frequency not significantly different from either of the other groups. Gastroesophageal reflux of bile and pancreatic enzymes, in addition to gastric acid may contribute to the greater esophageal damage often seen in Barrett's esophagus. The presence of duodenogastric reflux in these patients may have important pathophysiologic and therapeutic implications.

Epidemiology of reflux disease and reflux esophagitis

Symptomatic gastroesophageal reflux is a common medical problem. But only few data exist on the epidemiology of reflux disease (without inflammation) and reflux esophagitis. The literature is critically reviewed and ecological causes of gastroesophageal reflux are discussed. The prevalence of reflux esophagitis in Western countries is estimated to be 2% and that of reflux disease 5%. Sparse reports exist on the natural history of both diseases. They appear to have little if any effect on life expectancy. The main complications of reflux esophagitis are Barrett's esophagus, peptic stricture, ulceration and bleeding.

Extended and limited types of Barrett's esophagus in the adult

Columnar epithelium-lined lower esophagus (CLLE) or Barrett's esophagus was found in 34 patients diagnosed by endoscopic biopsy. In one-half of them, the CLLE extended up to 30 cm from the incisors (limited group) and in the other half, it reached above this level (extended group). Eight patients with stricture and limited CLLE had the lesion in the lower third of the esophagus, whereas 6 of 8 with strictures in the extended group had narrowing in the upper third of the esophagus. Two other patients with extended CLLE were seen with bleeding from Barrett's ulcer, 3 had adenocarcinoma, and the remaining 4 had CLLE without these complications. The three classic histologic types were encountered in both groups. However, in the extended group there was more of the intestinal type and less of the junctional type of epithelium, the latter being seen mostly in the limited group. The extended group had very low lower esophageal sphincter (LES) pressures (mean, 7.3 mm Hg) with severe reflux. The limited group had a higher mean LES pressure (11.2 mm Hg) with less severe reflux. In both groups, LES pressure and reflux improved following effective antireflux operation; some patients who continued to have demonstrable reflux and a lack of improvement in LES pressure despite antireflux operation, the disease progressed, as evidenced by extension of CLLE.

[Therapeutic results of peptic stenosis in the esophagus (author's transl)]

Of 118 patients treated for peptic stenosis between 1970 and 1979, 89 cases (75.4%) had developed in connection with endobrachyesophagus, i. e., as the result of primary reflux disease; 26 cases were the consequence of secondary reflux disease without endobrachyesophagus. In three cases the peptic stenosis had to be explained as the result of a local acid secretion. The treatment which followed was conservative (bougienage + Cimetidine/Antacids) or operative (bougienage + fundoplication). The results of the therapy varied according to the type of stenosis. In cases where the stenosis was located in the upper part (endobrachyesophagus), good results could be achieved with conservative therapy in 38.3% and with operative therapy, in 67.3%. The results were worse in terminal stenosis (conservative therapy, 45.5%; operative therapy, 60%). Retrospective analysis of unsuccessful treatment shows that predominantly scarred stenosis shows worse results than florid stenosis with recent esophagitis.

Conservative surgery in reflux stricture of the oesophagus associated with hiatal hernia

During a 7-year period, 130 patients with oesophageal stricture resulting from long-standing reflux oesophagitis and hiatal hernia were referred for surgery. Eighty-seven of these patients underwent conservative surgery consisting of intraoperative transgastric retrograde dilatation combined with one of two types of anti-reflux operation: in 34 patients (group 1) an Allison-type operation for hiatal hernia was undertaken, and in the remaining 53 patients (group 2), a Nissen-type fundoplication was carried out. In 22 patients in this latter group the oesophagogastric junction could not be brought down into the abdomen in spite of extensive oesophageal mobilization and the fundoplication was finally placed above the diaphragm. From the successful results in both groups (particularly in group 2), it is concluded that conservative surgery should be considered in cases of hiatal hernia with a reflux stricture that yields to intraoperative dilatation.