Short segment Barrett's oesophagus: prevalence, diagnosis and associations

Intestinal metaplasia in follow-up endoscopies among Asian patients with short-segment Barrett's esophagus: Regression, sampling error, and associated factors

BACKGROUND

The percentage of and factors associated with the regression of Barrett's esophagus (BE) or its characteristic intestinal metaplasia (IM) remain unclear, and conflicting results have been reported because of diverse regression and sampling error definitions. Thus, we investigated the rates of IM regression, sampling error, and associated factors.

METHODS

Forty-two patients with proven short-segment BE with IM who underwent two follow-up endoscopies with biopsies of Barrett's mucosa were retrospectively analyzed. Additional Alcian blue and MUC2 staining were done on the biopsy specimens without IM in hematoxylin-eosin staining. Only patients with negative hematoxylin-eosin, Alcian blue, and MUC2 staining for IM in both follow-up endoscopies were considered to have true regression. When all three stains were negative for IM in the first, but positive in the second follow-up endoscopy, we considered IM persisting and declared sampling error.

RESULTS

Among the 18 patients without IM at the first follow-up endoscopy, only five (11.9%) were judged to have true regression. Prolonged proton-pump inhibitor use was significantly associated with regression. Limited experience of the endoscopist, and insufficient biopsy number were significantly related to sampling error. Receiver operating characteristic (ROC) curve analysis showed the best cut-off value of the biopsy number/maximal-length (cm) ratio to predict sampling error was 2.25.

CONCLUSION

In our patients with short-segment BE, 11.9% experienced regression of IM. Prolonged proton-pump inhibitors treatment was associated with regression. An insufficient biopsy number was related to a missed IM, which may be eliminated by maintaining biopsy number/maximal-length (cm) ratio ≥2.25.

Mechanisms and pathophysiology of Barrett oesophagus

Barrett oesophagus, in which a metaplastic columnar mucosa that can predispose individuals to cancer development lines a portion of the distal oesophagus, is the only known precursor of oesophageal adenocarcinoma, the incidence of which has increased profoundly over the past several decades. Most evidence suggests that Barrett oesophagus develops from progenitor cells at the oesophagogastric junction that proliferate and undergo epithelial-mesenchymal transition as part of a wound-healing process that replaces oesophageal squamous epithelium damaged by gastroesophageal reflux disease (GERD). GERD also seems to induce reprogramming of key transcription factors in the progenitor cells, resulting in the development of the specialized intestinal metaplasia that is characteristic of Barrett oesophagus, probably through an intermediate step of metaplasia to cardiac mucosa. Genome-wide association studies suggest that patients with GERD who develop Barrett oesophagus might have an inherited predisposition to oesophageal metaplasia and that there is a shared genetic susceptibility to Barrett oesophagus and to several of its risk factors (such as GERD, obesity and cigarette smoking). In this Review, we discuss the mechanisms, pathophysiology, genetic predisposition and cells of origin of Barrett oesophagus, and opine on the clinical implications and future research directions.

Helicobacter pylori infection reduces the risk of Barrett's esophagus: A meta-analysis and systematic review

INTRODUCTION

The prevalence of Helicobacter pylori infection (HPI) has been decreasing in developed countries, with an increasing prevalence of Barrett's esophagus (BE) and esophageal adenocarcinoma (EAC) at the same time. The aim of our meta-analysis was to quantify the risk of BE in the context of HPI.

METHODS

A systematic search was conducted in 3 databases for studies on BE with data on prevalence of HPI from inception until December 2016. Odds ratios for BE in HPI were calculated by the random effects model with subgroup analyses for geographical location, presence of dysplasia in BE, and length of the BE segment.

RESULTS

Seventy-two studies were included in the meta-analysis, including 84 717 BE cases and 390 749 controls. The overall analysis showed that HPI reduces the risk of BE; OR = 0.68 (95% CI: 0.58-0.79, P < .001). Subgroup analyses revealed risk reduction in Asia OR = 0.53 (95% CI: 0.33-0.84, P = .007), Australia OR = 0.56 (95% CI: 0.39-0.80, P = .002), Europe OR = 0.77 (95% CI: 0.60-0.98, P = .035), and North-America OR = 0.59 (95% CI: 0.47-0.74, P < .001). The risk was significantly reduced for dysplastic BE, OR = 0.37 (95% CI: 0.26-0.51, P < .001) for non-dysplastic BE, OR = 0.51 (95% CI: 0.35-0.75, P = .001), and for long segment BE, OR = 0.25 (95% CI: 0.11-0.59, P = .001) in case of HPI.

CONCLUSIONS

This extensive meta-analysis provides additional evidence that HPI is associated with reduced risk of BE. Subgroup analyses confirmed that this risk reduction is independent of geographical location. HPI is associated with significantly lower risk of dysplastic, non-dysplastic, and long segment BE.

The prevalence of Helicobacter pylori infection and other risk factors among Mongolian dyspeptic patients who have a high incidence and mortality rate of gastric cancer

BACKGROUND

Mongolia has not only the second highest incidence rate but also the highest mortality rate for gastric cancer globally. In addition to gastric cancer, ulcerative disease complications are also life threatening; thus, investigating Helicobacter pylori infection and other risk factors is essential.

RESULTS

H.pylori infection was high in tested dyspeptic patients from all parts of Mongolia, with an overall infection rate of 80.0%. Logistic regression analysis showed that H. pylori infection was associated with gastritis (odds ratio; 9.0 ([95% confidence interval 5.0-16.2]); p < 0.0001). H. pylori infection (3.3 [2.0-5.4]; p < 0.0001) and > 40 years old (1.5 [1.0-2.0]; p < 0.02) were both associated with atrophy. However, > 40 years old (3.8 [2.4-6.0]; p < 0.0001) and high salt intakes (1.6 [1.0-2.3]; p < 0.02), but not H. pylori infection, were associated with intestinal metaplasia. Excessive amount of salt usage was dramatically higher in northern and western parts of Mongolia, where precancerous diseases, such as erosive esophagitis (for cardia cancer), severe atrophy, and intestinal metaplasia (for non-cardia cancer), were highly prevalent.

CONCLUSIONS

H. pylori infection was the major gastric health problem among the Mongolian population. In addition, environmental factors such as high salt intake worsened the clinical outcome. Therefore, a nationwide screening and eradication of H. pylori infection as well as salt-reducing measures should be implemented.

Australian clinical practice guidelines for the diagnosis and management of Barrett's esophagus and early esophageal adenocarcinoma

Barrett's esophagus (BE), a common condition, is the only known precursor to esophageal adenocarcinoma (EAC). There is uncertainty about the best way to manage BE as most people with BE never develop EAC and most patients diagnosed with EAC have no preceding diagnosis of BE. Moreover, there have been recent advances in knowledge and practice about the management of BE and early EAC. To aid clinical decision making in this rapidly moving field, Cancer Council Australia convened an expert working party to identify pertinent clinical questions. The questions covered a wide range of topics including endoscopic and histological definitions of BE and early EAC; prevalence, incidence, natural history, and risk factors for BE; and methods for managing BE and early EAC. The latter considered modification of lifestyle factors; screening and surveillance strategies; and medical, endoscopic, and surgical interventions. To answer each question, the working party systematically reviewed the literature and developed a set of recommendations through consensus. Evidence underpinning each recommendation was rated according to quality and applicability.

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.

The association between Barrett's esophagus and Helicobacter pylori infection: a meta-analysis

OBJECTIVE

The effect of Helicobacter pylori on Barrett's esophagus is poorly understood. We conducted a meta-analysis to summarize the existing literature examining the effect that H. pylori has on Barrett's esophagus.

DESIGN

 We performed a comprehensive search to identify studies pertaining to the association between H. pylori and Barrett's esophagus. We conducted meta-regression analyses to identify sources of variation in the effect of H. pylori on Barrett's esophagus.

RESULTS

 Our analysis included a total of 49 studies that examined the effect of H. pylori on Barrett's esophagus and seven studies that examined the effect of cag A positivity on Barrett's esophagus. Overall, H. pylori, and even more so cag A, tended to be protective for Barrett's esophagus in most studies; however, there was obvious heterogeneity across studies. The effect of H. pylori on Barrett's esophagus varied by geographic location and in the presence of selection and information biases. Only four studies were found without obvious selection and information bias, and these showed a protective effect of H. pylori on Barrett's esophagus (Relative risk = 0.46 [95% CI: 0.35, 0.60]).

CONCLUSIONS

 Estimates for the effect of H. pylori on Barrett's esophagus were heterogeneous across studies. We identified selection and information bias as potential sources of this heterogeneity. Few studies without obvious selection and information bias have been conducted to examine the effect of H. pylori on Barrett's esophagus, but in these, H. pylori infection is associated with a reduced risk of Barrett's esophagus.

Can Western endoscopists identify the end of the lower esophageal palisade vessels as a landmark of esophagogastric junction?

BACKGROUND AND AIM

The endoscopic landmark of esophagogastric junction (EGJ) for diagnosis of Barrett's esophagus (BE) differs between Japan and Western countries. Japanese endoscopists use the distal end of the lower esophageal palisade vessels to localize EGJ. In the West, endoscopists use the proximal gastric folds because of concerns that palisade vessels may be difficult to recognize. We evaluated whether there were differences between American and Japanese endoscopists in the recognition of palisade vessels.

METHOD

A total of 82 patients were enrolled in this study. Patients were referred for diagnostic esophagogastroduodenoendoscopy (EGD) at the Veterans Affairs Palo Alto Health Care System, from May to July 2008. American and Japanese endoscopists evaluated the EGJ of patients undergoing diagnostic EGD. We analyzed the differences in the recognition of the distal end of palisade vessels. We calculated the kappa statistic to measure interobserver variability.

RESULTS

Based on localization using the distal end of the palisade vessels, American and Japanese endoscopists identified the EGJ in 87.8% (72/82) and 89.0% (73/82) of cases, respectively. The kappa statistic for visualization of EGJ was 0.88 [95% confidence interval (CI): 0.73-1.00].

CONCLUSION

American and Japanese endoscopists similarly recognized the distal end of palisade vessels as EGJ.

Histology of metaplasia and dysplasia in Barrett's esophagus

The histologic diagnosis of Barrett's dysplasia requires the identification of intestinal metaplasia, which often presents a challenge due to sampling error, observer variation, and difficulty in histologic interpretation. Particularly problematic is the separation of negative, indefinite, and low-grade dysplasia, the varied histological appearances of high-grade dysplasia, and the diagnosis of suboptimal biopsy material. This article seeks to aid in the histological evaluation of metaplasia and dysplasia in Barrett's esophagus.

The influence of symptom type and duration on the fate of the metaplastic columnar-lined Barrett's oesophagus

BACKGROUND

Prolonged gastro-oesophageal reflux resulting in columnar metaplasia of the oesophagus is the main risk factor for oesophageal adenocarcinoma.

AIM

To examine the duration of symptoms and associations of different symptoms with the development of columnar-lined oesophagus, dysplasia and adenocarcinoma.

METHODS

UK multicentre cohort study of patients with columnar-lined oesophagus whose date of symptom onset (1082 patients) and/or types of symptoms reported (1681 patients) were documented. Follow-up was examined by analysis of histological reports from the registering centers.

RESULTS

Symptoms of dysphagia/odynophagia and nausea/vomiting were associated with development of dysplasia. High-grade dysplasia and adenocarcinoma were associated with dysphagia/odynophagia and weight loss. Median duration from symptom onset to detection of columnar-lined oesophagus without intestinal metaplasia: 2.6 years, columnar-lined oesophagus with intestinal metaplasia: 5.0 years, indefinite changes for dysplasia: 19.3 years and low-grade dysplasia: 30.0 years. One tenth of patients had developed high-grade dysplasia at 9.6 years and one tenth had developed adenocarcinoma at 13.8 years from symptom onset.

CONCLUSIONS

In patients with columnar-lined oesophagus, symptoms of dysphagia/odynophagia and nausea/vomiting were associated with a higher risk of development of dysplasia and adenocarcinoma. There is a trend for longer duration of symptoms to the detection of dysplasia.

Prevalence of Barrett's esophagus in patients with or without GERD symptoms: role of race, age, and gender

BACKGROUND

Gastroesophageal reflux disease is associated with a significantly increased risk of Barrett's esophagus (BE) and adenocarcinoma of the esophagus. Racial differences in the prevalence of BE are controversial. Our purpose was to study the prevalence of Barrett's esophagus in patients with and without gastroesophageal reflux disease (GERD) symptoms, and the differences between these two groups in terms of race, age, and sex.

METHODS

Esophagogastroduodenoscopy (EGD) reports from the PENTAX EndoPRO database for the Endoscopy Unit at the University of Texas Medical Branch from 2005 to 2007 were reviewed. Four hundred and ten patients who underwent upper endoscopy because of GERD symptoms that were not responding to proton pump inhibitor (PPI) therapy or with alarm symptoms and 4,047 patients undergoing upper endoscopy for other reasons without GERD symptoms were identified.

RESULTS

BE was significantly more common among males. The prevalence of BE was higher in patients with GERD symptoms than those without GERD symptoms. Overall, more cases of BE, dysplasia, and adenocarcinoma were found among the patients without GERD symptoms than those that underwent endoscopy because of GERD symptoms. The prevalence of BE among Caucasian, African American, Hispanic, and "other" groups with GERD symptoms were 5%, 2.56%, 4.4%, and 0%, respectively. The prevalence of BE among these racial groups without GERD symptoms were 1.9%, 0.9%, 1.57%, and 0.8%, respectively. The association between race and BE was not statistically significant (df = 3, P = 0.2628), including after adjusting for the presence of GERD symptoms (df = 3, P = 0.2947). Patients without GERD symptoms that presented with BE were significantly older than the patients without BE (P < 0.01).

CONCLUSIONS

BE is a male-dominant disease. The prevalence of Barrett's esophagus was not significant different among Caucasian, Hispanics, and African Americans. Most of the patients with BE, dysplasia, and adenocarcinoma did not have GERD symptoms.

Lower esophageal palisade vessels and the definition of Barrett's esophagus

The designated area of the columnar-lined esophagus (CLE) is anatomically defined by the distal limit of the lower esophageal palisade vessels (LEPV) and the term 'Barrett's esophagus' is equally used along with the name CLE in Japan. The aim of this study was to investigate the actual prevalence of CLE based on the Japanese criteria and to evaluate the criteria per se. A total of 42 esophagi consecutively resected at this institute were included. All subjects underwent a surgical resection for squamous cell carcinoma of the esophagus. The position of the LEPV, squamocolumnar junction, the prevalence of CLE and intestinal metaplasia were investigated both pre- and postoperatively. Preoperative endoscopy revealed CLE based on the Japanese criteria in half of all patients. In the resected specimens the distal limit of LEPV was lower than the squamocolumnar junction in 95.2%. In other words, almost all cases had CLE (equivalent to Barrett's mucosa in Japanese criteria). However, most of the CLE areas were very short and their average maximum length was only about 5 mm. In addition, no intestinal metaplasia was observed in any of the CLE cases. Almost all individuals might therefore be diagnosed to have CLE or Barrett's mucosa based on precise endoscopic observations in Japan. The CLE located in a small area, e.g. less than 5 mm, defined according to the LEPV criteria without any other factor concerning typical Barrett's esophagus such as signs of gastroesophageal reflux should therefore be excluded from consideration as a high-risk mucosa.

Barrett's columnar-lined oesophagus: demographic and lifestyle associations and adenocarcinoma risk

OBJECTIVES

Lifestyle and demographic risk factors for the development of oesophageal adenocarcinoma developing from columnar-lined oesophagus are not well defined.

METHODS

Demographic and lifestyle factors, endoscopy and histology reports were extracted from 1,761 subjects from seven UK centres. The associations of columnar-lined oesophagus with demographic and lifestyle factors and the development of adenocarcinoma were examined.

RESULTS

5.5% of patients had prevalent adenocarcinoma (more common in males, older patients, patients diagnosed earlier in the cohort and current or recent smokers). Adenocarcinoma incidence was 23 patients in 3,912 years or 0.59% per annum. Only increased age at diagnosis correlated with an increased risk of incident adenocarcinoma. There was no association with obesity or alcohol history.

CONCLUSIONS

Oesophageal adenocarcinoma occurs more commonly in older patients and is more frequent in males than females. Once columnar-lined oesophagus had been diagnosed, there were no other demographic or lifestyle factors which were predictive of the development of incident adenocarcinoma in this cohort.

Prevalence of Barrett's esophagus in individuals without typical symptoms of gastroesophageal reflux disease

BACKGROUND: Barrett’s esophagus, the major risk factor for esophageal adenocarcinoma, is detected in approximately 10%-14% of individuals submitted to upper endoscopy for the assessment of gastroesophageal reflux disease related symptoms. Prevalence studies of Barrett’s esophagus in individuals without typical symptoms of gastroesophageal reflux disease have reported rates ranging from 0.6% to 25%. AIM: To determine the prevalence of Barrett’s in a Brazilian population older than 50 years without typical symptoms of gastroesophageal reflux disease. METHODS: A total of 104 patients (51 men), mean age of 65 years, with an indication for upper endoscopy but without symptoms of heartburn and/or acid regurgitation (determined with a validated questionnaire) were recruited. Subjects submitted to upper endoscopic examination in the last 10 years or using antisecretory medication (proton pump inhibitors) during the last 6 months were not included. Methylene blue chromoscopy was performed during the endoscopic exam to facilitate identification of the metaplastic epithelium. RESULTS: Barrett’s esophagus was diagnosed endoscopically and confirmed by histology in four patients, all of them males. The metaplastic segment was short (less than 3 cm) and free of dysplasia in all patients. The prevalence of Barrett’s esophagus was 7.75% in the male population and 3.8% in the general population studied. CONCLUSION: Due to the low prevalence of Barrett’s esophagus found in the present study, associated with the finding of short-segment Barrett’s esophagus in all cases diagnosed and the absence of dysplasia in the material analyzed, endoscopic screening for Barrett’s esophagus in patients above the age of 50 without the classical symptoms of gastroesophageal reflux disease is not indicated for the Brazilian population.

Prevalence and topography of intestinal metaplasia in columnar lined esophagus

OBJECTIVES

Barrett's mucosa is considered as a mosaic of three epithelial types but little is known about the topography of intestinal metaplasia in columnar lined esophagus. The aims of the study were to determine the prevalence of intestinal metaplasia within long and short segments of columnar lined esophagus and to analyze the distribution of the intestinal metaplasia within long segments of Barrett's esophagus.

PATIENTS AND METHODS

The study was performed on the initial endoscopy carried out among 112 patients enrolled in an endoscopic surveillance program. Seventy-two patients with columnar mucosa extending more than 3 cm into the esophagus (group I) and 40 patients with a short segment of columnar mucosa (group II) had multiple biopsies according to a standardized protocol. 1163 biopsies were analyzed on the whole: 949 biopsies in group I and 214 biopsies in group II.

RESULTS

Intestinal metaplasia was identified among 650 (68.5%) and 50 (23.4%) biopsies in groups I and II respectively (P<10-7). The proportion of biopsies with foci of intestinal metaplasia increased significantly with the length of the columnar mucosa. The diagnosis of Barrett's esophagus was confirmed in 100% of the patients in group I and in 45% of the patients in group II. In long segments of Barrett's esophagus, intestinal metaplasia was more frequently observed in the 2 upper thirds of the columnar mucosa that in the lower third (P<10-7). Detailed mapping of the distribution of epithelial types within the columnar lined esophagus identified three patterns of distribution of intestinal metaplasia within long segments of Barrett's esophagus: unifocal, multifocal and diffuse, in 5%, 56% and 39% of the patients respectively. Dysplasia was present in 15% of patients with long segments of Barrett's esophagus and 11% of patients with short segments (NS).

CONCLUSION

The distribution of intestinal metaplasia within columnar lined esophagus is heterogeneous and three distinct patterns can be identified: unifocal, multifocal and diffuse. Considering the risk of sampling error, the current recommendations concerning the biopsy protocols are mandatory until the validation of new techniques such as chromoendoscopy or magnifying endoscopy.

Fe-S cluster proteins are intracellular targets for nitric oxide generated luminally at the gastro-oesophageal junction

In human, high concentrations of nitric oxide are generated at the gastro-oesophageal junction through entero-salivary recirculation of dietary nitrate. Nitric oxide is known to have a high affinity for Fe-S cluster proteins. The aim of this study is to investigate whether nitric oxide arising from the lumen diffuses into the adjacent tissue where it can interact with Fe-S proteins both in a rat animal model and human. An electron paramagnetic resonance detectable complex, dinitrosyl dithiolato iron complex (DNIC), was used as a biomarker for the interaction between Fe-S proteins and nitric oxide. The generation of the complex was evaluated in resected gastric tissue of nitrite-administered rat or biopsy specimens from human after nitrate ingestion. The activity of aconitase, one of the Fe-S cluster proteins, was also determined. The signal of the complex was observed at the rat gastro-oesophageal junction where luminal generation of nitric oxide from nitrite was maximal, and the intensity increased in a dose- and time-dependent manner. The appearance of the complex was accompanied by a significant inhibition of the aconitase activity at that site. The complex appeared in biopsy specimens from the gastro-oesophageal junction in three of five men after nitrate ingestion. Since DNIC is considered to be a decomposition product when Fe-S cluster proteins interact with nitric oxide, the appearance of the signal provides direct evidence that nitric oxide arising from the lumen can destroy such proteins. DNIC formation may represent the cellular mechanism responsible for the high prevalence of disease at the gastro-oesophageal junction.

Acetic acid allows effective selection of areas for obtaining biopsy samples in Barrett's esophagus

OBJECTIVE

The aim of this study was to determine whether macroscopic changes resulting from acetic acid application on the surface of columnar-lined esophagus allow regular, nonmagnifying, endoscopic identification of areas presenting dysplasia and/or cancer in Barrett's esophagus.

PATIENTS AND METHODS

A total of 100 patients (mean age, 53 years; range, 27-86 years) under surveillance because of short-segment (n=71) and long-segment (n=29) Barrett's esophagus, with no alterations of columnar-lined esophagus on standard endoscopy, were enrolled. After endoscopic examination, 3% acetic acid was sprayed on columnar-lined esophagus. The subsequent appearance of the mucosa was classified as: (1) Normal pattern: uniform reticulum along the entire columnar-lined esophagus. (2) Abnormal pattern: reticulum presenting areas of rough or irregular appearance. Biopsy samples were obtained from areas of normal and abnormal patterns, and the results of the corresponding histological studies were compared. All endoscopies were performed by the same investigator.

RESULTS

The endoscopic appearance, after acetic acid application, corresponded to a normal pattern in 85% of cases and an abnormal pattern in 15%. The percentage of dysplasia and adenocarcinoma in biopsy specimens was significantly higher in patients with rough or irregular areas (86.7%) than in those with normal uniform reticulum (0%) (P< 0.001). Sensitivity for the identification of areas of dysplasia or adenocarcinoma was 100% (95% confidence interval: 71.7-100%). Specificity was 97.7% (95% confidence interval: 91.2-99.6%).

CONCLUSIONS

This prospective study shows that acetic acid test is useful for standard, nonmagnifying, endoscopic detection of dysplasia and cancer in Barrett's esophagus.

The Veneto Region's Barrett's Oesophagus Registry: aims, methods, preliminary results

BACKGROUND

The natural history of Barrett's Oeosphagus is not completely clarified and Barrett's Oeosphagus Registries are considered useful tools to expand our knowledge on this disease. A Barrett's Oeosphagus Registry has been therefore established in the Veneto Region and neighbouring provinces.

AIMS

The aims of the Registry are to assess the demographical, endoscopical and histological characteristics of Barrett's Oeosphagus patients; the prevalence of non-invasive neoplasia and Barrett's Adenocarcinoma and the timing and incidence of Barrett's Oeosphagus progression to malignancy.

METHODS

An interdisciplinary committee of endoscopists, pathologists and information technology experts was established in 2004 to design a website-based Barrett's Oesophagus Registry for the Veneto Region and neighbouring north-eastern Italian provinces. Protocols for endoscopies and biopsies and standard reports were carefully defined.

RESULTS

In the first 18 months, 397 patients with endoscopically visible and histologically proven Barrett's Oeosphagus were enrolled in the Registry; the median age of these patients was 66 years (male:female=3:1). Most patients (75%) had a Short Segment of Barrett's Oesophagus (<or=3 cm) and only 1 in 4 had a Long Segment of Barrett's Oesophagus (>3 cm). Long Segment of Barrett's Oesophagus patients were 5 years older than the Short Segment of Barrett's Oesophagus patients (p<0.05), suggesting a progression from Short Segment of Barrett's Oesophagus to Long Segment of Barrett's Oesophagus. Though no data are available on the incidence of non-invasive neoplasia or Barrett's Adenocarcinoma (i.e., progression to cancer at least 12 months after enrolment), the prevalence of neoplastic lesions (found within 12 months of enrolment) was 5% for Short Segment of Barrett's Oesophagus and 19% for Long Segment of Barrett's Oesophagus, indicating that a careful multiple-biopsy endoscopic protocol is needed, especially when Long Segment of Barrett's Oesophagus are suspected at endoscopy. The prevalence of Barrett's Adenocarcinoma among patients with non-invasive neoplasia was 1/17 cases of low-grade non-invasive neoplasia and 2/3 cases of high-grade non-invasive neoplasia, indicating that these patients require strict endoscopic and bioptic follow-up.

CONCLUSION

A regional Barrett's Oeosphagus Registry is feasible at a relatively low cost and enables significant data to be collected in a relatively short time. The use of a standardised endoscopic nomenclature and report form, a strict biopsy protocol, a standard report for pathologists improves the quality of endoscopic and histological diagnoses.

Pathology of the gastroesophageal junction

The gastroesophageal junction (GEJ) is a poorly defined anatomic area that represents the junction etween the distal esophagus and the proximal stomach (cardia). The true anatomic GEJ corresponds to the most proximal aspect of the gastric folds, which represents an endoscopically apparent transition oint in most individuals. Many, if not most, adults, particularly those with either physiologic or logic GERD, have a proximally displaced Z-line indicating that the histologic squamocolumnar nction (SCJ) is located above the anatomic GEJ. The histologic characteristics of short segments of columnar mucosa located above the anatomic GEJ in these individuals are similar to the gastric cardia, ng composed of either pure mucous glands or mixed mucous glands/oxyntic glands. Although controversial, some authors believe that the cardia is normally composed, at birth, of surface mucinous columnar epithelium and underlying oxyntic glands identical to the gastric corpus, whereas others maintain that the true anatomic cardia is normally composed of mucinous columnar epithelium with underlying mucous glands or mixed mucous and oxyntic glands. However, the preponderance of evidence supports the latter theory and that the length of mucosa composed of either mucous, or mixed mucous glands/oxyntic glands, increases with age and is presumed to be related to ongoing GERD. Inflammation of the true gastric cardia (carditis), which is most often due to H. pylori infection, is difficult to distinguish from columnar metaplasia of the distal esophagus secondary to GERD. From a pathologist's perspective, the differential diagnosis of true gastric carditis from esophageal columnar metaplasia of the distal esophagus in GEJ biopsies is difficult, but a variety of clinical, pathologic, and immunohistochemical methods can be used to help separate these two disorders. Nearly one-third of patients who present for upper GI endoscopy without endoscopic evidence of BE reveal foci of intestinal metaplasia in the GEJ. There are some studies to suggest that the risk of dysplasia and cancer is different in patients with intestinal metaplasia in the cardia related to H. pylori infection versus those with metaplastic columnar epithelium in the distal esophagus related to GERD. Chronic inflammation is generally considered the predominant underlying stimulus for the development of columnar metaplasia in the GEJ, regardless of the etiology. Columnar metaplasia and intestinal metaplasia in the distal esophagus represents a squamous to columnar cell transition and there is some evidence that this occurs through an intermediate, or transitional, phase of intestinalization termed multilayered epithelium. In contrast, intestinal metaplasia that develops in the true gastric cardia secondary to H. pylori infection represents a columnar to columnar metaplastic reaction. This review will focus on the clinical, pathologic, and pathogenetic aspects of GERD and H. pylori-induced inflammation of the GEJ region.

The Montreal definition and classification of gastroesophageal reflux disease: a global evidence-based consensus

OBJECTIVES

A globally acceptable definition and classification of gastroesophageal reflux disease (GERD) is desirable for research and clinical practice. The aim of this initiative was to develop a consensus definition and classification that would be useful for patients, physicians, and regulatory agencies.

METHODS

A modified Delphi process was employed to reach consensus using repeated iterative voting. A series of statements was developed by a working group of five experts after a systematic review of the literature in three databases (Embase, Cochrane trials register, Medline). Over a period of 2 yr, the statements were developed, modified, and approved through four rounds of voting. The voting group consisted of 44 experts from 18 countries. The final vote was conducted on a 6-point scale and consensus was defined a priori as agreement by two-thirds of the participants.

RESULTS

The level of agreement strengthened throughout the process with two-thirds of the participants agreeing with 86%, 88%, 94%, and 100% of statements at each vote, respectively. At the final vote, 94% of the final 51 statements were approved by 90% of the Consensus Group, and 90% of statements were accepted with strong agreement or minor reservation. GERD was defined as a condition that develops when the reflux of stomach contents causes troublesome symptoms and/or complications. The disease was subclassified into esophageal and extraesophageal syndromes. Novel aspects of the new definition include a patient-centered approach that is independent of endoscopic findings, subclassification of the disease into discrete syndromes, and the recognition of laryngitis, cough, asthma, and dental erosions as possible GERD syndromes. It also proposes a new definition for suspected and proven Barrett's esophagus.

CONCLUSIONS

Evidence-based global consensus definitions are possible despite differences in terminology and language, prevalence, and manifestations of the disease in different countries. A global consensus definition for GERD may simplify disease management, allow collaborative research, and make studies more generalizable, assisting patients, physicians, and regulatory agencies.

Barrett's esophagus: pathologic considerations and implications for treatment

Barrett's esophagus (BE) is a complication of chronic reflux that results in the replacement of esophageal squamous epithelium with columnar epithelium. BE is endoscopically recognized and pathologically confirmed. The presence of goblet cells is diagnostic. The pathologist must also determine if dysplasia or invasive cancer is present. Acceptable terms for dysplasia are no dysplasia, indefinite for dysplasia, low-grade dysplasia (LGD), or high-grade dysplasia (HGD). It can be difficult to differentiate HGD from intramucosal cancer (IMC) in an endoscopic biopsy specimen. Treatment based on this differentiation is problematic. Indications for treatment of BE are similar to those of patients without BE. Treatment will not cause clinically significant regression of BE or prevent progression to cancer. Cancer development following successful antireflux surgery is uncommon.

Short-Segment Barrett's Esophagus and Adenocarcinoma

Barrett's esophagus is a known risk factor for the development of adenocarcinoma of the esophagus and esophagogastric junction. Based on the length of the columnar segment at endoscopy, Barrett's esophagus has been arbitrarily separated into two broad categories: long-segment and short-segment. The rapid rise in the incidence of esophageal adenocarcinoma has generated sustained research interest in this lesion. Studies have shown that although the prevalence of short-segment Barrett's esophagus is higher than that of long-segment Barrett's esophagus, the risk of developing dysplasia and adenocarcinoma may actually be lower in those patients with short segment Barrett's esophagus. Nonetheless, both dysplasia and esophageal adenocarcinoma have been reported in patients with short-segment Barrett's esophagus, making this arbitrary distinction clinically unimportant. The current surveillance guidelines remain the same for both short- and long-segment Barrett's esophagus. Another key issue is differentiating short-segment Barrett's esophagus from intestinal metaplasia of the gastric cardia. The latter is distinct from esophageal intestinal metaplasia (ie, Barrett's esophagus) and probably does not warrant surveillance.

[Correct diagnosis for indication in gastroesophageal reflux disease]

For diagnosis and quantitation of gastroesophageal reflux disease, a number of different examinations are available. The simplest are the patient's history and complaints as well as the proton pump inhibitor test; both methods have a positive predictive value of 65% to 70%. Esophagogastroduodenoscopy is the gold standard for differentiation between erosive and nonerosive reflux disease. Biopsy does not enhance the significance of endoscopy except for proof of Barrett's epithelium or malignant degeneration. Twenty-four-hour pH monitoring has the highest sensitivity and specificity for the diagnosis of gastroesophageal reflux disease. Barium swallow provides only additional information concerning hiatal hernia or stenosis. Manometry can clarify lower esophageal sphincter insufficiency or motility disorders of the tubular esophagus. However, the available studies show that manometry has no influence on postoperative outcome after fundoplication. The indication for medical therapy can primarily be based only on the history and complaints of the patient. As surgical therapy affords a high degree of diagnostic accuracy, at least endoscopy and 24-h pH monitoring are necessary for indication.

Use of an improved zirconyl hematoxylin stain in the diagnosis of Barrett's esophagus

Barrett's esophagus is a precancerous condition characterized by replacement of the normal stratified squamous epithelium by a simple columnar epithelium with goblet cells that secrete an acidic mucin. As originally formulated, fresh solutions of zirconyl hematoxylin stain goblet cells poorly. An improved formula, quintupling the amount of oxidant, yields zirconyl hematoxylin solutions that stain goblet cells darkly even when fresh. The improved zirconyl hematoxylin can be used in place of alcian blue in the diagnosis of Barrett's esophagus. The ingredients of zirconyl hematoxylin are always readily available and are generally recognized as safe.

Increased Barrett's esophagus for the decade between 1991 and 2000 at a single university medical center

Barrett's esophagus is being diagnosed increasingly in the United States. The aim of this study was to determine whether the increased diagnosis of Barrett's esophagus is due to endoscopic reporting and/or a truly increasing rate. This retrospective study reviewed 18,183 endoscopy reports at Temple University Hospital from January 1991 through December 2000. Annual rates of new cases of endoscopically suspected Barrett's esophagus were determined. Biopsy results were reviewed for the diagnosis of Barrett's esophagus (i.e., specialized intestinal metaplasia). Rates of Barrett's esophagus increased from 3.22 to 8.28 per 100 endoscopies (257%; P < 0.01) on endoscopy and from 0.67 to 2.76 per 100 endoscopies (412%; P < 0.01) on histology from 1991 to 2000. Twenty-four and seven-tenths percent (252/1020) of patients suspected at endoscopy to have Barrett's esophagus were confirmed by histology. This study demonstrates an increasing rate of new cases of suspected Barrett's esophagus on endoscopy and confirmed Barrett's esophagus on histology over the last decade. The endoscopic impression of Barrett's esophagus was about four times higher than the confirmed diagnosis of Barrett's esophagus (intestinal metaplasia) on histology.

Unraveling the mystery of the gastroesophageal junction: a pathologist's perspective

The gastroesophageal junction (GEJ), which is defined as the point where the distal esophagus joins the proximal stomach (cardia), is a short anatomic area that is commonly exposed to the injurious effects of GERD and/or Helicobacter pylori infection. These disorders often lead to inflammation and intestinal metaplasia (IM) of this anatomic region. The true gastric cardia is an extremely short segment (<0.4 mm) of mucosa that is typically composed of pure mucous glands, or mixed mucous/oxyntic glands that are histologically indistinguishable from metaplastic mucinous columnar epithelium of the distal esophagus. In patients with GERD, whether physiologic or pathologic, the length of cardia-type epithelium increases and extends proximally above the level of the anatomic GEJ into the distal esophagus. Columnar metaplasia of the distal esophagus represents a squamous to columnar metaplastic reaction that develops from an esophageal stem cell and may pass through an intermediate phase characterized by the presence of a type of epithelium that possesses a mixture of squamous and columnar features, termed multilayered epithelium. In contrast, IM of the gastric cardia represents a columnar to columnar cell metaplastic reaction that develops from a gastric stem cell located in the deep foveolar compartment of the gastric mucosa. Intestinal metaplasia, particularly the incomplete type, is widely believed to represent the precursor lesion upon which dysplasia and cancer arises. The frequency of IM is probably greater in metaplastic columnar epithelium in the esophagus secondary to GERD, than in cases of true gastric carditis secondary to H. pylori, and may be a reason why there is a higher risk of carcinoma in the former compared to the latter. A variety of clinical, endoscopic, histologic, and histochemical methods can be used to distinguish GERD-induced columnar metaplasia of the distal esophagus from H. pylori-induced inflammation of true gastric cardia, and these are outlined in this review, but further controlled studies are needed to critically evaluate these techniques. Further prospective trials are needed to adequately evaluate the different etiologic and pathogenetic mechanisms and, most importantly, the risk of malignancy in these two conditions.

Diffusion of cytotoxic concentrations of nitric oxide generated luminally at the gastro-oesophageal junction of rats

BACKGROUND

In humans, high concentrations of nitric oxide are generated luminally at the gastro-oesophageal junction through enterosalivary recirculation of dietary nitrate.

AIM

To investigate whether luminal nitric oxide can diffuse into the adjacent digestive tissue and alter tissue integrity.

METHODS

We designed an animal model using Wistar rats in which physiological concentrations of nitrite and acidified ascorbic acid were administered separately so that the two reactants first meet to form nitric oxide at the gastro-oesophageal junction. Luminal and tissue concentrations of nitric oxide were measured with an electrode and an electron paramagnetic resonance spectrometer, respectively. Concentrations of glutathione in the tissue were measured as a marker of nitrosative stress.

RESULTS

High concentrations of luminal nitric oxide were generated locally at the gastro-oesophageal junction of nitrite administered rats, reproducing a phenomenon observed in humans. High levels of nitric oxide were also detected largely in the superficial epithelium of the gastro-oesophageal junction. The concentration of tissue glutathione at the gastro-oesophageal junction was significantly lower in nitrite administered rats compared with control rats, whereas that in the distal stomach was similar in the two rat groups.

CONCLUSIONS

Using an animal model, this study demonstrated that nitric oxide generated in the lumen diffuses into the adjacent gastric tissue to a substantial degree, leading to localised consumption of glutathione in the tissue. Nitrosative stress induced by this mechanism may be involved in the high prevalence of inflammation and metaplasia, and subsequent development of neoplastic disease at this site.

Prevalence of precancerous and other metaplasia in the distal oesophagus and gastro-oesophageal junction

OBJECTIVE

The epidemiology of Barrett's oesophagus (BO) is characterized by divergent results. The aim of this study was to estimate the prevalence of BO and intestinal metaplasia (IM) at the gastro-oesophageal junction (GOJ) in a population-based series of patients referred for first-time gastroscopy.

MATERIAL AND METHODS

Consecutive patients who underwent endoscopy for the first time at endoscopy units exclusively serving defined catchment areas were invited to take part in the study. Biopsies were taken immediately below the GOJ and from the distal oesophagus, and clinical data were recorded.

RESULTS

A total of 769 patients (mean age 53 years, 43% M) were examined. Overall IM prevalence was 14%. BO was noted in 4%. Overall, the prevalence of IM increased by 8% (95% CI 6-10%) per year of age. BO patients were predominately women (69%). Presence of cardia-type mucosa in the cardia increased with age from 25% among the youngest to 59% among the oldest patients. Pancreatic acinar metaplasia (PAM) was found in 18%.

CONCLUSIONS

While BO is not common among Swedish gastroscopy patients, IM and PAM are found in every 7th and 6th patient, respectively. Age-dependent increments in prevalence suggest that not only BO and IM, but also cardia-type mucosa are acquired and/or progressive lesions.

The interplay between Helicobacter pylori, gastro-oesophageal reflux disease, and intestinal metaplasia

Helicobacter pylori infection and gastro-oesophageal reflux disease (GERD) account for most upper gastrointestinal pathologies with a wide spectrum of clinical manifestations. The interplay of both conditions is complex, in part intriguing, and has become a matter of debate because of conflicting results. The cardia is an area where both H pylori and abnormal GERD exert their damaging potential, inducing inflammation and its consequences, such as intestinal metaplasia. While the role of intestinal metaplasia within columnar lined epithelium (Barrett's oesophagus) in the context of GERD is well established as a risk for neoplasia development, the role of intestinal metaplasia at the cardia in the context of H pylori infection is unclear. A particular challenge is the distinction of intestinal metaplasia as a consequence of GERD or H pylori if both conditions are concomitant. Available data on this issue, including follow up of a small patient series, are presented, but more studies are required to shed light on this issue because they will help to identify those patients that need surveillance.

Cytokeratin 7/20 and MUC1, 2, 5AC, and 6 expression patterns in Barrett's esophagus and intestinal metaplasia of the stomach: intestinal metaplasia of the cardia is related to Barrett's esophagus

Intestinal metaplasia (IM) in endoscopic biopsies obtained from close to the gastroesophageal junction may represent IM of the cardia (CIM) or Barrett's esophagus (BE), which have different malignant potentials despite similar morphology. This study compared cytokeratin (CK) 7/20 and mucin (MUC1, 2, 5AC, and 6) immunopatterns in biopsies from BE (n = 41), CIM (n = 35), and antral gastric IM (AIM, n = 37) to evaluate their roles as diagnostic aids. CK7 and CK20 expression was described as absent, patchy (superficial and deep), continuous superficial only, continuous deep only, and diffuse. Eleven different combinations of CK7/20 expression were seen. Since CK20 staining was positive in all cases, four main patterns were defined on the basis of the observed CK7 staining as 1, absent; 2, patchy (superficial and/or deep); 3, diffuse; and 4, continuous superficial only. Overall CK7 positivity (regardless of pattern) was higher in BE and CIM than in AIM. CK patterns 3 and 4 were also higher in BE and CIM than in AIM. For either pattern 3 or 4, the positive and negative predictive values for BE versus AIM were 95% and 67%, respectively. MUC1 was rarely expressed in BE and CIM compared with AIM, whereas the opposite was noted for MUC5AC expression. MUC2 and MUC6 expression was similar in all locations. In conclusion, diffuse or continuous superficial CK7 staining is highly characteristic of BE and CIM and contrasts with AIM. It is, however, not very sensitive. CK20 profiles have no added value. Mucin expression also differs between BE and CIM versus AIM, but the specificity of any pattern is insufficient for distinction in individual cases. Importantly, CK and MUC expression patterns in BE and CIM are virtually indistinguishable, limiting their use in this differential and raising the question of whether they are biologically related.

Review article: towards consistency in the endoscopic diagnosis of Barrett's oesophagus and columnar metaplasia

Barrett's oesophagus is associated with severe reflux disease and is a risk factor for oesophageal adenocarcinoma. However, there is a lack of consensus on how to assess the presence and extent of Barrett's oesophagus in clinical practice. A diagnosis of Barrett's oesophagus is currently based on the recognition of an abnormal oesophageal mucosa at endoscopy. However, a diagnosis cannot be made solely on this basis, and a true diagnosis requires the identification of an area suspicious for columnar metaplasia at endoscopy, followed by histological confirmation. Currently, difficulties in the assessment of Barrett's oesophagus include a lack of consistent definitions of endoscopic landmarks (such as the gastro-oesophageal and squamo-columnar junctions), a lack of standardization of descriptions of the extent of Barrett's oesophagus, and limited communication between the endoscopist and the pathologist, which hampers accurate histological confirmation. It is therefore important to develop an endoscopic description of Barrett's oesophagus, with a clear definition of endoscopic landmarks, to determine, amongst other things, whether anti-reflux therapy produces regression or a reduction in the length of Barrett's oesophagus. With this background, a subgroup of the International Working Group on the Classification of Oesophagitis was charged with developing a simple, practicable classification system, suitable for use with standard endoscopes, which would be easy to apply in clinical practice and in large clinical studies. Described in this review are a series of propositions and an overview of the 'CM classification', developed by the International Working Group on the Classification of Oesophagitis, to facilitate the endoscopic description of Barrett's oesophagus. It is hoped that these propositions will be the first step in the development of standard endoscopic diagnostic criteria for Barrett's oesophagus, relevant to clinical practice and clinical research.

Endoscopic findings of adenocarcinoma arising from short-segment Barrett's esophagus

Adenocarcinoma arising from short-segment Barrett's esophagus (SSBE) is rare in Japan, although the incidence of this condition is increasing in Western countries. Four cases of early adenocarcinoma arising from SSBE were diagnosed and treated at Niigata-prefectural Yoshida Hospital. All patients were male, variously 55, 71, 73 and 79 years of age. All four patients had long-term gastroesophageal reflux disease, although one patient had erosive esophagitis and three patients did not have erosive esophagitis. Three patients were diagnosed as having Helicobacter pylori-free stomach. All adenocarcinomas occurred close to the squamocolumnar junction. Patients with SSBE should undergo detailed endoscopic examination of the squamocolumnar junction in order to detect early adenocarcinoma arising from SSBE.

Barrett's esophagus: prevalence and its relationship with dyspeptic symptoms

BACKGROUND AND AIM

Barrett's metaplasia is a premalign condition which plays a pivotal role in the development of esophageal adenocarcinoma. It is considered a complication of chronic gastroesophageal reflux disease. Although esophageal adenocarcinoma is an uncommon cancer, its incidence is rapidly increasing. The aims of the present study were to determine the prevalence of Barrett's metaplasia in outpatients referred for gastroscopy for upper gastrointestinal symptoms, and to clarify the relationship between Barrett's metaplasia and upper gastrointestinal symptoms.

METHODS

Three-hundred and ninety-five consecutive dyspeptic patients, never previously investigated, underwent gastroscopy and were enrolled into the study.

RESULTS

Barrett's metaplasia was detected in 29 patients (7.4%). The age-specific prevalence of Barrett's metaplasia increased with age. In multivariate analysis, Barrett's metaplasia was independently and positively related to age, sex and duration of symptoms, but not with upper gastrointestinal symptoms. In univariate analysis, Barrett's metaplasia was significantly more common in patients with antral intestinal metaplasia (24%) and presence of hiatal hernia (65.5%), compared with those with normal endoscopic findings (6.2% and 39.2%, respectively, p = 0.001).

CONCLUSION

Symptoms do not predict Barrett's metaplasia. Barrett's metaplasia is age-related and more common in patients with a longer duration of symptoms, presence of hiatal hernia and antral intestinal metaplasia.

Studies of acid exposure immediately above the gastro-oesophageal squamocolumnar junction: evidence of short segment reflux

BACKGROUND AND AIMS

Oesophageal pH is conventionally recorded from a point 5 cm above the lower oesophageal sphincter. However, the mucosal changes of reflux oesophagitis and intestinal metaplasia tend to affect the segment of oesophagus distal to this and close to the squamocolumnar junction. This study set out to investigate oesophageal acid exposure of squamous mucosa close to the squamocolumnar junction.

METHODS

Dual channel 24 hour pH monitoring was carried out in 11 patients with endoscopy negative dyspepsia and no evidence of gastro-oesophageal reflux by conventional oesophageal pH metry. Oesophageal pH was recorded from electrodes positioned 5 mm and 55 mm proximal to the squamocolumnar junction. A novel technique was developed using metal clips to secure the pH catheter to the oesophageal mucosa and maintain these electrode positions. Oesophageal manometry indicated that the distal electrode was within the high pressure zone of the lower oesophageal sphincter.

RESULTS

We found that 24 hour oesophageal acid exposure (per cent time pH <4) was greater 5 mm above the squamocolumnar junction compared with the conventional position 5 cm more proximal (11.7% v 1.8%; p<0.001). The greater acid exposure at the distal versus the conventional site was apparent in both the upright (12.7% v 2.3%) and supine (10.5% v 1.3%) positions, as well as during preprandial (14.2% v 1.6%) and postprandial (21.8% v 2.8%) periods (p<0.001 for each). The number of reflux events recorded close to the squamocolumnar junction was also higher than at the conventional position (168 v 33; p<0.001). There was no correlation between acid exposure at the two sites.

CONCLUSIONS

The squamous mucosa of the most distal oesophagus is exposed to substantial acidic reflux, even in patients without evidence of conventional reflux disease. This short segment reflux may explain the high incidence of metaplasia and neoplasia at the gastro-oesophageal junction.

Factors influencing the development of Barrett's epithelium in the esophageal remnant postesophagectomy

BACKGROUND

Barrett's esophagus results from chronic reflux of both acid and bile. Reflux of gastric and duodenal contents is facilitated through the denervated stomach following esophagectomy, but the development of Barrett's changes in this model and the relationship to gastric and esophageal physiology is poorly understood.

AIMS

To document the development of new Barrett's changes, i.e., columnar metaplasia or specialized intestinal metaplasia (SIM) above the anastomosis, and relate this to the recovery of gastric acid production, acid and bile reflux, manometry, and symptoms.

PATIENTS AND METHODS

Forty-eight patients at a median follow-up of 26 months (range = 12-67) postesophagectomy underwent endoscopy with biopsies taken 1-2 cm above the anastomosis. The indication for esophagectomy had been adenocarcinoma (n = 27), high-grade dysplasia (n = 2), and squamous cell cancer (n = 19). Physiology studies were performed in 27 patients and included manometry (n = 25), intraluminal gastric pH (n = 24), as well as simultaneous 24-hour esophageal pH (n = 27) and bile monitoring (n = 20).

RESULTS

Duodenogastric reflux increased over time, with differences between patients greater than and less than 3 years postesophagectomy for acid (p = 0.04) and bile (p = 0.02). Twenty-four patients (50%) developed columnar metaplasia and of these 13 had SIM. The prevalence of columnar metaplasia did not relate to the magnitude of acid or bile reflux, to preoperative neoadjuvant therapies, or to the original tumor histology. The duration of reflux was most significant, with increasing prevalence over time, with SIM in 13 patients at a median of 61 months postesophagectomy compared with 20 months in the 35 patients who were SIM-negative (p < 0.006). Supine reflux correlated with symptoms.

CONCLUSIONS

The development of Barrett's epithelium is frequent after esophagectomy, is time-related, reflecting chronic acid and bile exposure, and is not specific for adenocarcinoma or the presence of previous Barrett's epithelium. This model may represent a useful in vivo model of the pathogenesis of Barrett's metaplasia and tumorigenesis.

Screening for Barrett's esophagus in colonoscopy patients with and without heartburn

BACKGROUND & AIMS

The population prevalence of Barrett's esophagus (BE) is uncertain. Our aim was to describe the prevalence of BE in a volunteer population.

METHODS

Upper endoscopy (EGD) was performed in 961 persons with no prior history of EGD who were scheduled for colonoscopy. Symptom questionnaires were completed prior to endoscopy. Biopsy specimens were taken from the gastric cardia and any columnar mucosa extending > or =5 mm into the tubular esophagus and from the stomach for H. pylori infection in the last 812 patients.

RESULTS

The study sample was biased toward persons undergoing colonoscopy, males, and persons with upper GI symptoms. The prevalence of BE was 65 of 961 (6.8%) patients, including 12 (1.2%) with long-segment BE (LSBE). Among 556 subjects who had never had heartburn, the prevalences of BE and LSBE were 5.6% and 0.36%, respectively. Among 384 subjects with a history of any heartburn, the prevalences of BE and LSBE were 8.3% and 2.6%, respectively. In a univariate analysis, LSBE was more common in those with any heartburn vs. those with no heartburn (P = 0.01), but the sample size was insufficient to allow multivariate analysis of predictors of LSBE. In a multivariate analysis, BE was associated with increasing age (P = 0.02), white race (P = 0.03), and negative H. pylori status (P = 0.04). Overall, BE was not associated with heartburn, although heartburn was more common in persons with LSBE or circumferential short segments.

CONCLUSIONS

LSBE is very uncommon in patients who have no history of heartburn. SSBE is relatively common in persons age > or =40 years with no prior endoscopy, irrespective of heartburn history.

Can symptoms predict endoscopic findings in GERD?

BACKGROUND

It is difficult to decide which patients with reflux symptoms require endoscopy. The aim of this study was to develop a scoring system to predict esophageal findings at endoscopy.

METHODS

A consecutive sample of 1011 adult patients scheduled for upper endoscopy were asked to complete a validated symptom questionnaire. The endoscopy reports were abstracted. Individual logistic regression models were developed to predict esophagitis, Barrett's esophagus (long and short segment) and esophageal stricture, including Schatzki's ring.

RESULTS

Reflux esophagitis was independently associated with heartburn frequency (p<0.0001) but not severity or duration (p>0.05). Barrett's esophagus was associated with the duration of acid regurgitation (p<0.005) but not with frequency or severity (p>0.05). Strictures were associated with dysphagia severity (p<0.0001) and duration (p<0.0001) but not frequency (p>0.05). At a sensitivity of 80%, the models had a specificity of 49% for esophagitis, 57% for Barrett's esophagus, and 68% for strictures. At a specificity of 80%, the sensitivities were 51% for esophagitis, 62% for Barrett's esophagus and 71% for strictures.

CONCLUSIONS

Endoscopic findings were associated with distinct attributes of reflux symptoms. Symptoms are only modestly predictive of findings at endoscopy.

Intestinal metaplasia in the distal esophagus and correlation with symptoms of gastroesophageal reflux disease

Barrett's esophagus is a metaplastic condition that occurs in patients with gastroesophageal reflux disease (GERD) and its importance lies in its potential to develop adenocarcinoma of the esophagus. The diagnosis of Barrett's esophagus is based on finding of intestinal metaplasia of at least 3 cm of the distal esophagus. The diagnosis of intestinal metaplasia of less than 3 cm of the distal esophagus is controversial, regarding implications with GERD, adenocarcinoma, and Helicobacter pylori. The aims of the study were to determine the prevalence of intestinal metaplasia in the distal esophagus in patients with short segments of esophageal columnar-appearing mucosa (less than 3 cm), diagnosed endoscopically, in two groups of patients, with and without symptoms of GERD. In total, 97 patients were examined, with endoscopic finding of esophageal columnar-appearing mucosa less than 3 cm. From the total, 52 patients had symptoms of GERD and 45 patients were without these symptoms. These patients were subjected to distal esophageal biopsies obtained immediately below the epithelial transition. The biopsies were stained with hematoxylin-eosin and alcian blue at pH 2.5. Urease test for H. pylori detection in two fragments of gastric antrum was carried out. The presence of intestinal metaplasia in the distal esophagus was diagnosed in 16 (30.8%) patients in the GERD group and 12 (26.7%) patients without GERD symptoms. No statistical differences were observed (P = 0.82; 95% CI: 0.61-2.17). The variables sex, mean age and positivity for H. pylori did not show statistical differences. This study diagnosed high prevalence of intestinal metaplasia in the distal esophagus with columnar-appearing mucosa, less than 3 cm, with no statistical differences in the two groups studied with and without GERD symptoms.

Barrett's esophagus: environmental influences in the progression of dysplasia

Barrett's esophagus (BE) is composed of multiple lineages including Paneth cells and endocrine cells in addition to gastric and intestinal cells. Although the origin of the BE stem cell is a matter of conjecture, the stem cells are clearly multipotent, and therefore the phenotype is restricted by genomic imprinting (termed restricted potency). Recent evidence suggests that the microenvironment may select various lineages. In this regard the proportion of gastric and specialized intestinal metaplastic cells has been attributed to the composition of the refluxate, acid or bile, respectively. Experimental evidence also implicates specific xenobiotics in this process, including bile acids. In particular we discuss the potential biologic roles of bile acids in epithelial adaptation from in vivo and in vitro models.

Trends in incidence and prevalence of specialized intestinal metaplasia, barrett's esophagus, and adenocarcinoma of the gastroesophageal junction

Most available information on the epidemiology of Barrettacute;s esophagus (BE) relates to patients with long segments (> 3 cm) of specialized intestinal metaplasia (SIM). Its prevalence is 3% in patients undergoing endoscopy for reflux symptoms and 1% in those undergoing endoscopy for any clinical indication. The latter prevalence is similar to the 1% found in autopsy series. A "silent majority" with BE remain unrecognized in the general population. BE is more common in men, and the prevalence rises with age. Recent endoscopic series document a rise in the diagnosis of endoscopically apparent short segments (< 3 cm) of BE (SSBE). The prevalence of SSBE in both unselected and reflux patients is 8% to 12%. Specialized intestinal metaplasia at the cardia, below a normal-appearing squamocolumnar junction, has been reported to vary from 6% to 25% in patients presenting for upper endoscopy. Unlike patients with long segment Barrett's esophagus (LSBE), the role of gastroesophageal reflux disease in the pathogenesis of SSBE and SIM of the cardia is controversial. Recent data suggest that the etiology of SIM of the cardia might be secondary to Helicobacter pylori infection, although the role of other environmental factors cannot be ruled out. The incidence of adenocarcinoma of the esophagus and esophagogastric juction (EGJ) has been increasing over the past 15 years in Western countries. Surgical series and population-based studies show that by 1994 adenocarcinomas of the esophagus accounted for half of all esophageal cancer among white men. LSBE and SSBE predispose to the development of adenocarcinoma of the esophagus and EGJ. The role of SIM of the cardia as a precursor lesion for EGJ adenocarcinoma is still unclear. The prevalences of dysplasia in LSBE and SSBE are around 6% and 8%, respectively. The incidence of adenocarcinoma in patients with LSBE is about 1 in 100 patient-years. Cancer risk for SSBE and SIM at the cardia is unknown. Smoking and obesity increase the risk for esophageal and EGJ adenocarcinomas.

Cromoendoscopia com azul de metileno para diagnóstico de esôfago de Barrett

RACIONAL: O esôfago de Barrett é uma condição na qual a mucosa escamosa esofágica é substituída por metaplasia intestinal especializada, que predispõe o paciente ao desenvolvimento de adenocarcinoma esofágico. Este é precedido por displasia e carcinoma precoce; o rastreamento dessas lesões faz-se através de endoscopias digestivas periódicas com biopsias randomizadas. A incidência aumentada desse, tem despertado interesse no desenvolvimento de novas técnicas endoscópicas, como a cromoendoscopia com azul de metileno, para melhorar a identificação do esôfago de Barrett e suas complicações. OBJETIVO: Determinar se as biopsias dirigidas pela cromoendoscopia com azul de metileno oferecem vantagem em relação ao método convencional na detecção do esôfago de Barrett. MATERIAL E MÉTODO: Estudaram-se 45 pacientes com diagnóstico prévio de esôfago de Barrett, todos submetidos a dois exames de endoscopia digestiva alta com biopsias, em intervalo de 4 semanas, um convencional e outro com aplicação do corante, no período entre abril e outubro de 2002. RESULTADOS: Os resultados histológicos das biopsias de todos os exames foram comparados. Observou-se sensibilidade de 62,5%, especificidade de 15,4%, valor preditivo positivo de 57,7% e valor preditivo negativo de 18,2%. Não houve diferença significativa quanto ao número de biopsias. O tempo de duração da técnica de cromoendoscopia foi significativamente maior quando comparado ao da técnica convencional. CONCLUSÃO: Não se observou vantagem na utilização da cromoendoscopia em relação à técnica randomizada no diagnóstico do esôfago de Barrett.

Role of surveillance in intestinal metaplasia of the esophagus and gastroesophageal junction

This article reviews current concepts of cancer surveillance in esophageal columnar metaplasia (Barrett's esophagus) and intestinal metaplasia at the gastroesophageal junction. An overview is given of the available data on the prevalence of intestinal metaplasia in biopsies from the distal esophagus and from the gastroesophageal junction. Furthermore, special attention is given to the endoscopic detection of dysplasia and early malignancy. Finally, the costs of endoscopic surveillance and its effect on mortality rates from esophageal adenocarcinoma are discussed.

Adenomatous polyposis coli gene, beta-catenin, and E-cadherin expression in proximal and distal gastric cancers and precursor lesions: an immunohistochemical study using tissue microarrays

The aims of this study were (1) to compare protein expression of adenomatous polyposis coli (APC) gene, beta-catenin, and E-cadherin between proximal and distal gastric adenocarcinomas and (2) to investigate their use as markers of cancer risk in intestinal metaplasia (IM). The epidemiology of proximal (cardia and gastroesophageal junction) and distal (antrum and corpus) gastric carcinomas is strikingly different despite similar morphologies. Carcinoma of the distal stomach is decreasing in incidence, whereas proximal carcinomas are increasing in incidence more than any other cancer in the Western world. This phenomenon has so far not been satisfactorily explained. IM is a well-established precursor for adenocarcinoma in the distal stomach but less so in the proximal stomach. However, its specificity as a predictor of gastric carcinoma is very low. Abnormalities of APC, beta-catenin, and E-cadherin are implicated in carcinogenesis of the stomach and may show aberrant expression at early stages of the neoplastic process. This study evaluated their immunoprofiles in 3 groups: biopsies showing normal mucosa (n = 108), biopsies showing IM (n = 99), and gastric cancer resections (n = 117). In the last group, carcinoma and noninvolved mucosa were studied. All groups included material from both proximal and distal locations. The results of this study showed that there were no differences between proximal and distal locations with regard to APC, beta-catenin, or E-cadherin expression. In both locations, high normal expression rates for all 3 molecules were present in biopsies showing normal gastric mucosa or IM and noninvolved mucosa from gastric cancer resections. In carcinomas, there was a significant decrease in both APC and E-cadherin expression, whereas beta-catenin showed abnormal cytoplasmic and nuclear staining. Diffuse-type cancers showed significantly lower E-cadherin expression than intestinal types. Noninvolved mucosa from cancer resections showed normal APC, beta-catenin, and E-cadherin expression regardless of adjacent tumor type and whether the mucosa was morphologically normal or showed IM. In conclusion, proximal and distal gastric carcinomas show no differences in expression of APC, beta-catenin, or E-cadherin; thus, the observed abnormalities do not seem to contribute to the observed epidemiologic differences between these tumors. Because loss of APC, decreased E-cadherin, or abnormal beta-catenin expression did not occur in IM, even when associated with carcinoma these immunostains are unlikely to be of value in the assessment of malignant potential in IM.