Barrett's esophagus in Japanese patients: its prevalence, form, and elongation

Asymmetrical circumferential distribution of esophagogastric junctional lesions: anatomical and physiological considerations

Several components of the gastrointestinal tract including the esophagogastric junction (EGJ) show circumferential asymmetry in the formation of pathological lesions, which is caused by the morphological and functional asymmetry of the gastrointestinal tract. Pressure in the lower esophageal sphincter (LES) is higher on the left posterior side as compared to the right anterior side, which may partly explain why Mallory-Weiss tears frequently occur on the right side wall of the EGJ. Lower LES pressure in the right anterior wall may not effectively prevent gastroesophageal reflux on this side and may be a reason why esophageal erosions in patients with reflux esophagitis, short segment Barrett's esophagus, and adenocarcinomas associated with short segment Barrett's esophagus are frequently found in the right anterior wall of the esophagus. In addition, acidic gastroesophageal reflux may also cause rupture of esophageal varices predominantly on that side. Thus, asymmetrical LES pressure may be a cause of the right anterior side predominance of diseases found in this part of the gastrointestinal tract.

Endoscopic definition of esophagogastric junction for diagnosis of Barrett's esophagus: importance of systematic education and training

The diagnosis of Barrett's esophagus (BE) requires an accurate recognition of the columnar-lined esophagus at endoscopy. However, a universally accepted standardized endoscopic grading system of BE was lacking prior to the development of the Prague 'circumferential and maximal' criteria. In this system, the landmark for the esophagogastric junction (EGJ) is the proximal end of the gastric folds, not the distal end of the palisade vessels, which are used to endoscopically identify the EGJ in Japan. Although the circumferential and maximal criteria are clinically relevant, an important shortcoming of this system may be failure to identify short-segment BE, a lesion that is found frequently in the Japanese. To compare the diagnostic yield for BE when using the palisade vessels versus gastric folds as a landmark for the EGJ, we evaluated interobserver diagnostic concordance. The endoscopic identification of the EGJ using both landmarks resulted in unacceptably low kappa coefficients of reliability. However, there was a statistically significant improvement after the participants were thoroughly trained in identification of the EGJ during the endoscopic study. Although it remains controversial which landmark is better for the endoscopic diagnosis of BE, it is important to systematically educate and train endoscopists in order to improve diagnostic consistency in patients with BE.