Histopathology of the endoscopic esophagogastric junction in patients with gastroesophageal reflux disease

Relationship between endoscopic gastroesophageal valve grading and mean nocturnal baseline impedance and postreflux swallow-induced peristaltic wave index in patients with gastroesophageal reflux disease

This study aimed to investigate the relationship between endoscopic gastroesophageal valve grading and mean nocturnal baseline impedance (MNBI) and postreflux swallow-induced peristaltic wave index (PSPWI) in patients with gastroesophageal reflux disease (GERD). A total of 120 patients diagnosed with GERD disease were included in the study. According to the classification of endoscopic gastroesophageal valves, the patients were divided into 5 groups, group 1 as baseline group, and Group 2-4 as Hill grade I-IV. Basic information about the patients was collected, including age and gender. The mean nocturnal baseline impedance and creep wave index induced by swallowing after rumination were measured by high resolution creep measurement technique. Through statistical analysis, the relationship between valve classification and observation index was discussed. In terms of MNBI, impedance values gradually decreased with increasing valve classification. The average impedance of the Grade 1 group was 23.5 mm Hg/cm2, while the average impedance of the Grade 5 group was 15.2 mm Hg/cm2. This reduction showed a significant decreasing trend (P < .001). In addition, in terms of the peristaltic wave index caused by swallowing after regurgitation, the peristaltic wave index gradually increased with the increase of valve classification. The mean index in the Grade 1 group was 1.8 beats/min, while the mean index in the Grade 5 group was 3.6 beats/min. This increase showed a significant positive relationship (P < .001). Endoscopic gastroesophageal valve grading was significantly correlated with MNBI and PSPWI in patients with GERD. These observations can serve as useful tools for assessing the severity of GERD and monitoring disease progression.

Association between hiatal hernia and Barrett's esophagus: an updated meta-analysis with trial sequential analysis

Background

Barrett's esophagus (BE) is a precursor of esophageal adenocarcinoma. It is critical to recognize the risk factors associated with BE.

Objectives

The present meta-analysis aims to systematically estimate the association of hiatal hernia with the risk of BE.

Design

A meta-analysis with trial sequential analysis.

Data sources and methods

The PubMed, EMBASE, and Cochrane Library databases were searched. The pooled odds ratios (ORs) and adjusted ORs (aORs) with their 95% confidence intervals (CIs) were calculated for the combined estimation of unadjusted data and data adjusted for confounders, respectively. Heterogeneity was quantified using the Cochrane Q test and I² statistics. Subgroup, meta-regression, and leave-one-out sensitivity analyses were employed to explore the sources of heterogeneity.

Results

Forty-seven studies with 131,517 participants were included. Based on the unadjusted data from 47 studies, hiatal hernia was significantly associated with an increased risk of any length BE (OR = 3.91, 95% CI = 3.31-4.62, p < 0.001). The heterogeneity was significant (I² = 77%; p < 0.001) and the definition of controls (p = 0.014) might be a potential contributor to heterogeneity. Based on the adjusted data from 14 studies, this positive association remained (aOR = 3.26, 95% CI = 2.44-4.35, p < 0.001). The heterogeneity was also significant (I² = 65%; p < 0.001). Meta-analysis of seven studies demonstrated that hiatal hernia was significantly associated with an increased risk of long-segment BE (LSBE) (OR = 10.01, 95% CI = 4.16-24.06, p < 0.001). The heterogeneity was significant (I² = 78%; p < 0.001). Meta-analysis of seven studies also demonstrated that hiatal hernia was significantly associated with an increased risk of short-segment BE (OR = 2.76, 95% CI = 2.05-3.71, p < 0.001). The heterogeneity was not significant (I² = 30%; p = 0.201).

Conclusion

Hiatal hernia should be a significant risk factor for BE, especially LSBE.

Registration

PROSPERO registration number CRD42022367376.

Intestinal Metaplasia of the "Cardia": Accurate Differentiation of Gastric or Esophageal Origin With an Expanded Biopsy Protocol

Whether intestinal metaplasia (IM) distal to the endoscopic gastroesophageal junction (GEJ), that is, the cardia, is gastric or esophageal or both is controversial. Biopsies from this region are believed to be unreliable in resolving this issue and are not recommended. Our objective was to develop an accurate method of histologic diagnosis for IM of the cardia. An expanded biopsy protocol was employed in 986 patients irrespective of indication for endoscopy. This sampled columnar lined esophagus (CLE) when present, the endoscopic GEJ defined by the proximal limit of rugal folds, the area 1 cm distal to the GEJ, and distal stomach. The prevalence and associations of IM in these 4 locations were evaluated. IM was found in 79/91 patients with CLE above the GEJ. This was significantly associated with IM at the GEJ in 40/79 patients (P<0.001). The biopsy taken distal to the endoscopic GEJ had IM in 21/79 patients. No patient with CLE had IM in the distal stomach. In patients without CLE, IM was present at or distal to the endoscopic GEJ in 221 patients. In 32 patients, this was significantly associated with IM in the distal stomach (P<0.001). The remaining 189/986 (19.2%) patients had IM limited to the GEJ region. These data, in association with recent evidence, indicate that IM limited to the area distal to the GEJ in patients without distal gastric IM represents microscopic Barrett esophagus in a dilated distal esophagus. This is presently mistaken for IM of the proximal stomach because of a flawed endoscopic definition of the GEJ.

New evidence defining the pathology and pathogenesis of lower esophageal sphincter damage

Background

Present diagnosis and management of gastroesophageal reflux disease (GERD) has resulted in a dramatic increase in the incidence of esophageal adenocarcinoma. This is due to failure to identify pathologic changes of early GERD; at present, pathology is limited to management of Barrett esophagus (BE).

Methods

Convincing evidence have confirmed that cardiac mucosa distal to the squamocolumnar junction in the endoscopically normal person is a metaplastic GERD-induced esophageal epithelium, and not a normal proximal gastric epithelium.

Results

When cardiac mucosa is recognized as a metaplastic esophageal epithelium, it becomes self-evident that the present endoscopic definition of the gastro-esophageal junction is incorrect, and there exists a dilated distal esophagus (DDE) in what is incorrectly termed the “gastric cardia” presently mistaken for proximal stomach. It also becomes clear that the length of the DDE correlates with the presence and severity of GERD and represents the pathology of the entire spectrum of GERD. Further, it allows recognition that the DDE, measured as the gap between esophageal squamous epithelium and gastric oxyntic mucosa that is composed of cardiac mucosa, represents the pathologic anatomy of damage to the abdominal segment of the lower esophageal sphincter (LES).

Conclusion

The new understanding of the significance of cardiac mucosa provides a new and highly accurate histologic method of assessment of LES damage, the primary cause of GERD. This opens a new door to complete histologic assessment of GERD from its etiologic standpoint and to new research that permit early diagnosis of GERD at its outset. Ultimately, such early diagnosis has the potential to reverse the increasing trend of esophageal adenocarcinoma.

Does anti-reflux surgery disrupt the pathway of Barrett's esophagus progression to cancer?

In patients with Barrett's esophagus (BE), anti-reflux surgery aims to sustainable control reflux symptoms and heal reflux induced esophageal mucosal inflammation and prevent progression of BE to adenocarcinoma. There is growing evidence that beside gastric acid, bile salts in refluxed duodenal juice are responsible for the development and progression of BE. However, the pathogenesis of BE progression and the metaplasia-dysplasia-carcinoma sequence of the adenocarcinoma of the esophagus (EAC) is multifactorial and occurs over long natural time course. After anti-reflux surgery significant levels of regression from metaplastic Barrett's to non-metaplastic epithelium as well as from dysplastic to non-dysplastic BE have been observed and a randomized trial showed that sufficient surgical reflux control reduces the risk of Barrett's progression significantly when compared to medical treatment. Thus, large cohort studies show significant reduced risk of EAC in patients suffering from gastroesophageal reflux disease (GERD) with and without BE after anti-reflux surgery. Even after anti-reflux surgery the risk for EAC remains elevated in patients with BE and the right moment of intercepting the progressive nature of GERD has to be discussed in future. The paper also addresses the impact of anti-reflux surgery, endoscopic ablation and life style therapies for the management of GERD, BE and cancer prevention.

How the pathologist can aid in the assessment of gastroesophageal reflux disease

PURPOSE OF REVIEW

To provide new concepts regarding the early pathologic changes of gastroesophageal reflux disease (GERD) that are associated with damage to the lower esophageal sphincter (LES).

RECENT FINDINGS

A body of evidence exists that cardiac mucosa is a metaplastic esophageal epithelium rather than a normal gastric epithelium. Recent studies in asymptomatic volunteers suggest a potential mechanism for cardiac metaplasia in the squamous epithelium of the esophagus.

SUMMARY

The concept that cardiac mucosa is esophageal, not gastric, suggests that the widely accepted endoscopic definition of the gastroesophageal junction (GEJ) is incorrect. I propose that the true GEJ is the proximal extent of gastric oxyntic epithelium. If there is cardiac mucosa lining proximal rugal folds, that cardiac mucosa-lined region is the dilated distal esophagus, not the proximal stomach. The dilated distal esophagus is the pathologic expression of damage to the abdominal segment of the LES. This concept suggests a new test for measuring damage to the abdominal LES and a new understanding of the disease of GERD based on the measured amount of LES damage. This opens the door to new research and change in objectives in the management of reflux disease from control of symptoms to prevention of complications such as Barrett's esophagus and adenocarcinoma.

Histologic Features Associated With Columnar-lined Esophagus in Distal Esophageal and Gastroesophageal Junction (GEJ) Biopsies From GERD Patients: A Community-based Population Study

There are inherent problems with the endoscopic and pathologic criteria for columnar-lined esophagus (CLE). Furthermore, the clinical and biological significance of an irregular squamocolumnar junction (SCJ) is unclear. The aim of this study was to evaluate the association between histologic features in SCJ biopsies and CLE and to gain insight into the significance of an irregular SCJ. The study was a cross-sectional analysis of 2176 mucosal biopsies of the SCJ from 544 patients in a large prospective community clinic-based study of gastroesophageal reflux disease in Washington State. Biopsy samples were evaluated blindly for a wide variety of histologic features, such as the presence and type of mucosal glands, submucosal glands and ducts, goblet cells, multilayered epithelium (ME), inflammation, and buried columnar epithelium. Histologic findings were correlated with the endoscopic findings (normal Z-line, irregular Z-line, or CLE) and evaluated by logistic regression and receiver operating characteristic analysis.Five histologic features were associated with CLE: pure mucous glands, ME, presence of goblet cells, ≥50% of crypts with goblet cells, and buried columnar epithelium. Pure oxyntic glands were inversely associated with CLE. The features most strongly related to CLE included biopsies with ≥50% of crypts with goblet cells, ME, and mucosal gland type (area under the curve=0.71; 95% confidence interval=0.66-0.76). Patients with an irregular Z-line were histologically similar to those with CLE. Certain histologic features in biopsies of the SCJ are associated with the presence of CLE. Irregularity of the Z-line is probably indicative of ultrashort segment CLE, instead of being a potential variation of normal.

Review on novel concepts of columnar lined esophagus

BACKGROUND

Columnar lined esophagus (CLE) is a marker for gastroesophageal reflux and associates with an increased cancer risk among those with Barrett's esophagus. Recent studies fostered the development of integrated CLE concepts.

METHODS

Using PubMed, we conducted a review of studies on novel histopathological concepts of nondysplastic CLE.

RESULTS

Two histopathological concepts-the squamo-oxyntic gap (SOG) and the dilated distal esophagus (DDE), currently model our novel understanding of CLE. As a consequence of reflux, SOG interposes between the squamous lined esophagus and the oxyntic mucosa of the proximal stomach. Thus the SOG describes the histopathology of CLE within the tubular esophagus and the DDE, which is known to develop at the cost of a shortened lower esophageal sphincter and foster increased acid gastric reflux. Histopathological studies of the lower end of the esophagus indicate, that the DDE is reflux damaged, dilated, gastric type folds forming esophagus and cannot be differentiated from proximal stomach by endoscopy. While the endoscopically visible squamocolumnar junction (SCJ) defines the proximal limit of the SOG, the assessment of the distal limit requires the histopathology of measured multilevel biopsies. Within the SOG, CLE types distribute along a distinct zonation with intestinal metaplasia (IM; Barrett's esophagus) and/or cardiac mucosa (CM) at the SCJ and oxyntocardiac mucosa (OCM) within the distal portion of the SOG. The zonation follows the pH-gradient across the distal esophagus. Diagnosis of SOG and DDE includes endoscopy, histopathology of measured multi-level biopsies from the distal esophagus, function, and radiologic tests. CM and OCM do not require treatment and are surveilled in 5 year intervals, unless they associate with life quality impairing symptoms, which demand medical or surgical therapy. In the presence of an increased cancer risk profile, it is justified to consider radiofrequency ablation (RFA) of IM within clinical studies in order to prevent the progression to dysplasia and cancer. Dysplasia justifies RFA ± endoscopic resection.

CONCLUSIONS

SOG and DDE represent novel concepts fusing the morphological and functional aspects of CLE. Future studies should examine the impact of SOG and DDE for monitoring and management of gastroesophageal reflux disease (GERD).

Hiatal hernia and the risk of Barrett's esophagus

BACKGROUND AND AIM

Barrett's esophagus has been associated with the presence of hiatal hernia; however, to date no meta-analysis of the relationship has been performed. We aimed to conduct a systematic review and meta-analysis, providing a quantitative estimate of the increased risk of Barrett's esophagus associated with hiatal hernia.

METHODS

A search was conducted through four electronic databases (Medline, PubMed, Embase, and Current Contents Connect) to 4 April 2012, for observational studies of Barrett's esophagus patients. We calculated pooled odds ratios and 95% confidence intervals using a random effects model for the association of hiatal hernia with any length Barrett's esophagus, as well as with short segment Barrett's esophagus and long segment Barrett's esophagus. 33 studies comprising 4390 Barrett's esophagus patients were eligible for the meta-analysis.

RESULTS

Hiatal hernia was associated with an increased risk of Barrett's esophagus of any length (odds ratio 3.94; 95% confidence interval 3.02-5.13). Heterogeneity was present (I2 = 82.03%, P < 0.001), and the Egger test for publication bias was significant (P = 0.0005). The short segment Barrett's esophagus subgroup analysis likewise showed an increased risk (odds ratio 2.87; 95% confidence interval 1.75-4.70). The strongest association was between hiatal hernia and long segment Barrett's esophagus (odds ratio 12.67; 95% confidence interval 8.33-19.25). The increased risk was present even after adjusting for reflux and body mass index.

CONCLUSIONS

 The presence of hiatal hernia was associated with an increased risk of Barrett's esophagus, even after adjusting for clinically significant confounders. The strongest association was found between hiatal hernia and long segment Barrett's esophagus.

The dilated distal esophagus: a new entity that is the pathologic basis of early gastroesophageal reflux disease

Present management algorithms for patients with gastroesophageal reflux disease (GERD) limit endoscopy to patients with advanced disease. When endoscopy is performed, biopsy is limited to patients who have a visible columnar-lined esophagus. Biopsy is not recommended for patients whose endoscopy is normal. This algorithm results in the failure to evaluate patients with early stages of GERD at a pathologic level. We report 714 patients with normal endoscopic findings irrespective of symptoms who had adequate biopsies taken from the squamocolumnar junction and the area 1-cm distal to this from mucosa that had rugal folds. Concurrent biopsies were also taken from the gastric body and/or antrum. All patients had a gap between their esophageal squamous epithelium and gastric oxyntic mucosa in the junctional region composed of oxyntocardiac ± cardiac ± intestinal epithelia. A total of 643 (90.1%) patients had no significant pathology in the gastric antrum and/or body, indicating that the squamooxyntic gap was an isolated abnormality in this region in all but 71 (9.9%) patients. The gap contained only oxyntocardiac epithelium in 71 (9.9%) patients, cardiac mucosa without intestinal metaplasia in 482 (67.5%) patients, and intestinal metaplasia in 161 (22.6%) patients. The pathologic interpretation of biopsies taken from the gastroesophageal junction is confusing and has significant interobserver variation. This results from lack of agreement as to whether these biopsies originate in the proximal stomach ("gastric cardia") or in the esophagus. We provide evidence that the presence of oxyntocardiac ± cardiac ± intestinal epithelia in biopsies from patients who are endoscopically normal is diagnostic of a dilated GERD-damaged distal esophagus. The dilated distal esophagus is the pathologic manifestation of destruction of the abdominal segment of the lower esophageal sphincter. Its presence is the pathologic basis of early GERD, which is missed if patients who are endoscopically normal are not biopsied, as is the present recommendation. Its recognition allows for accurate and evidence-based interpretation of biopsies from this region and removes the present confusion and permits the development of a reproducible pathologic diagnostic method.

Definition of the esophagogastric junction: a critical mini review

CONTEXT

Accurate diagnosis of diseases involving the esophagogastric junction (EGJ) is challenging because of difficulty in defining the EGJ endoscopically and histologically. Recent research results have redefined the EGJ, and the endoscopic and histologic diagnostic criteria of the mucosal EGJ have become available.

OBJECTIVE

To review the recent literature on endoscopy, histology, and pathology of the EGJ with critical analysis.

DATA SOURCES

Recently published research articles and guidelines in the peer-reviewed core journals and personal research results in this field.

CONCLUSIONS

At present, the mucosal EGJ can be defined endoscopically as the distal ends of esophageal longitudinal vessels that meet the proximal ends of gastric longitudinal mucosal folds. However, histologic validation of this criterion is needed. The histologic criteria of the EGJ include the distal ends of esophageal squamous mucosa, deep esophageal glands or ducts, or multilayered epithelium. The squamocolumnar junction is not a reliable landmark of the EGJ in patients with diseases involving the EGJ, such as hiatal hernias.

The histologic squamo-oxyntic gap: an accurate and reproducible diagnostic marker of gastroesophageal reflux disease

The present definition of gastroesophageal reflux disease (GERD) is based on clinical criteria that are difficult to reproduce accurately. This study provides a method to develop a histologic definition of GERD based on biopsies obtained from the affected esophagus. Pathology reports from 1655 patients who had upper gastrointestinal endoscopy and biopsy according to a systematic protocol were reviewed. Biopsies were obtained from the esophagus, around the gastroesophageal junction and the stomach: proximal, body, and antrum. Patients who had oxyntocardiac±cardiac±intestinal epithelia between the squamous epithelium proximally and the proximal limit of gastric oxyntic mucosa distally were defined as having a squamo-oxyntic gap. The length of the squamo-oxyntic gap varied from less than 1 cm in 1399 (84.5%) patients to greater than 5 cm in 80 (4.8%) of the patients. Only oxyntocardiac epithelium was seen in 190 (11.5%) of the patients, oxyntocardiac and cardiac epithelia in 898 (54.3%), and intestinal metaplasia in addition to the other 2 epithelial types in 567 (34.2%). The prevalence of intestinal metaplasia was directly proportional to length of the squamo-oxyntic gap, being 24.3% (340/1399) when the length was <1 cm, and 83.5% (147/176) with length 1 to 5 cm. All patients with a length more than 5 cm had intestinal metaplasia. The distribution of the 3 epithelia was constant irrespective of the length of the squamocolumnar gap; intestinal metaplasia, when present, was seen maximally in the proximal region of the gap, cardiac epithelium intermediate and oxyntocardiac epithelium in the most distal segment of the gap. The squamo-oxyntic gap started in a dilated region distal to the end of the tubular esophagus and distal to the proximal limit of the rugal folds and extended into the tubular esophagus. Distal gastric biopsies showed no evidence of significant inflammation, intestinal metaplasia or Helicobacter pylori infection in 1543 (93.2%) of the patients, indicating that the squamo-oxyntic gap was largely independent of gastric pathology. We provide evidence that the squamo-oxyntic gap is equivalent to the columnar-lined esophagus. Its presence is a specific and sensitive indicator of reflux and can be used as a cellular criterion to define GERD. The length of the squamo-oxyntic gap provides an accurate assessment of the severity of chronic GERD. The distal limit of the squamo-oxyntic gap, which is the junction between oxyntocardiac and gastric oxyntic epithelium is the true gastroesophageal junction. The presence of intestinal metaplasia within the squamo-oxyntic gap is the most accurate risk indicator for esophageal adenocarcinoma and defines Barrett esophagus.