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Edelmuth RCL, Riascos MC, Al Asadi H, Greenberg JA, Miranda IC, Najah H, Crawford CV, Schnoll-Sussman FH, Finnerty BM, Fahey TJ, Zarnegar R. Gastric development of pancreatic acinar cell metaplasia after Vonoprazan therapy in rats. Surg Endosc 2023; 37:9366-9372. [PMID: 37644156 DOI: 10.1007/s00464-023-10371-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 07/30/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND Vonoprazan is a new acid-suppressing drug that received FDA approval in 2022. It reversibly inhibits gastric acid secretion by competing with the potassium ions on the luminal surface of the parietal cells (potassium-competitive acid blockers or P-CABs). Vonoprazan has been on the market for a short time and there are many clinical trials to support its clinical application. However, medical experience and comprehensive clinical data is still limited, especially on how and if, gastric histology is altered due to therapy. METHODS A 12-week experiment trial with 30 Wistar rats was to assess the presence of gastrointestinal morphologic abnormalities upon administration of omeprazole and vonoprazan. At six weeks of age, rats were randomly assigned to one of 5 groups: (1) saline as negative control group, (2) oral omeprazole (40 mg/kg), as positive control group, (3) oral omeprazole (40 mg/kg) for 4 weeks, proceeded by 8 weeks off omeprazole, (4) oral vonoprazan (4 mg/kg), as positive control group, and (5) oral vonoprazan (4 mg/kg) for 4 weeks, proceeded by 8 weeks off vonoprazan. RESULTS We identified non-inflammatory alterations characterized by parietal (oxyntic) cell loss and chief (zymogen) cell hyperplasia and replacement by pancreatic acinar cell metaplasia (PACM). No significant abnormalities were identified in any other tissues in the hepatobiliary and gastrointestinal tracts. CONCLUSION PACM has been reported in gastric mucosa, at the esophagogastric junction, at the distal esophagus, and in Barrett esophagus. However, the pathogenesis of this entity is still unclear. Whereas some authors have suggested that PACM is an acquired process others have raised the possibility of PACM being congenital in nature. Our results suggest that the duration of vonoprazan administration at a dose of 4 mg/kg plays an important role in the development of PACM.
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Affiliation(s)
- Rodrigo C L Edelmuth
- Department of Surgery, Division of Endocrine & Minimally Invasive Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 525 East 68Th Street, K-836, New York, NY, 10065, USA
- Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Maria Cristina Riascos
- Department of Surgery, Division of Endocrine & Minimally Invasive Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 525 East 68Th Street, K-836, New York, NY, 10065, USA
| | - Hala Al Asadi
- Department of Surgery, Division of Endocrine & Minimally Invasive Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 525 East 68Th Street, K-836, New York, NY, 10065, USA
| | - Jacques A Greenberg
- Department of Surgery, Division of Endocrine & Minimally Invasive Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 525 East 68Th Street, K-836, New York, NY, 10065, USA
| | - Ileana C Miranda
- Laboratory of Comparative Pathology, Weill Cornell Medical College, New York-Presbyterian Hospital, Memorial Sloan Kettering Cancer Center, The Rockefeller University, New York, NY, USA
| | - Haythem Najah
- Department of Surgery, Division of Endocrine & Minimally Invasive Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 525 East 68Th Street, K-836, New York, NY, 10065, USA
| | - Carl V Crawford
- Division of Gastroenterology and Hepatology, Department of Medicine, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA
| | - Felice H Schnoll-Sussman
- Division of Gastroenterology and Hepatology, Department of Medicine, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA
| | - Brendan M Finnerty
- Department of Surgery, Division of Endocrine & Minimally Invasive Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 525 East 68Th Street, K-836, New York, NY, 10065, USA
| | - Thomas J Fahey
- Department of Surgery, Division of Endocrine & Minimally Invasive Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 525 East 68Th Street, K-836, New York, NY, 10065, USA
| | - Rasa Zarnegar
- Department of Surgery, Division of Endocrine & Minimally Invasive Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 525 East 68Th Street, K-836, New York, NY, 10065, USA.
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Andersen M, Ren B, Romano ME, Schutz SN, Rothstein RI, Suriawinata AA, Liu X, Lisovsky M. Pancreatic acinar metaplasia at the gastroesophageal junction is associated with protective effect against intestinal metaplasia in patients with gastroesophageal reflux disease. Hum Pathol 2023; 139:1-8. [PMID: 37364824 DOI: 10.1016/j.humpath.2023.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 06/15/2023] [Accepted: 06/21/2023] [Indexed: 06/28/2023]
Abstract
Anecdotal evidence suggests that pancreatic acinar metaplasia (PAM) and intestinal metaplasia (IM) overlap infrequently at the gastroesophageal junction/distal esophagus (GEJ/DE). The goal of this study was to evaluate the significance of PAM at GEJ/DE in relation to IM in patients with gastroesophageal reflux disease (GERD). Group 1 comprised 230 consecutive patients with GEJ/DE biopsies (80.6% with GERD symptoms). Group 2 comprised 151 patients with established GERD and GEJ/DE biopsies taken before Nissen fundoplication. Group 3 comprised 540 consecutive patients used for a follow-up study of PAM. PAM was present in 15.7%-15.9% and IM in 24.8%-31.1% of patients in groups 1 and 2, respectively. PAM-IM overlap was present in 2.2%-3.3%, respectively. Patients with PAM were, on average, 6-12 years younger than patients with IM, and were predominantly female (72.2%-75%), in contrast to patients with IM (47.3%-32%). In the unadjusted logistic regression model, patients with PAM were 69%-65% less likely to also have IM, as compared to patients without PAM. In the fully adjusted model, patients with PAM were 35%-61% less likely to also have IM, although the P-value was not significant. Follow-up analysis of patients with PAM from group 3 (n = 28) demonstrated the prevalence of IM and PAM in subsequent biopsies at 7.1% and 60.7%, respectively. No cases showed PAM-IM overlap on follow-up. The data suggests that PAM at the GEJ/DE is associated with protective effect against IM and thus could be useful as a marker of decreased susceptibility to IM.
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Affiliation(s)
- Michael Andersen
- Department of Pathology and Laboratory Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH, 02215, USA
| | - Bing Ren
- Department of Pathology and Laboratory Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH, 02215, USA
| | - Megan E Romano
- Department of Epidemiology, Geisel School of Medicine at Dartmouth, Lebanon, NH, 03755, USA
| | - Shannon N Schutz
- Department of Pathology and Laboratory Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH, 02215, USA
| | - Richard I Rothstein
- Department of Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH, 03756, USA
| | - Arief A Suriawinata
- Department of Pathology and Laboratory Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH, 02215, USA
| | - Xiaoying Liu
- Department of Pathology and Laboratory Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH, 02215, USA
| | - Mikhail Lisovsky
- Department of Pathology and Laboratory Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH, 02215, USA.
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Shibli F, Fass OZ, Teramoto OM, Remes-Troche JM, Rangan V, Kurin M, Fass R. Esophageal Hypocontractile Disorders and Hiatal Hernia Size Are Predictors for Long Segment Barrett's Esophagus. J Neurogastroenterol Motil 2023; 29:31-37. [PMID: 36606434 PMCID: PMC9837537 DOI: 10.5056/jnm21255] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 07/22/2022] [Accepted: 08/06/2022] [Indexed: 01/07/2023] Open
Abstract
Background/Aims Presently, there is paucity of information about clinical predictors, especially esophageal motor abnormalities, for long segment Barrett's esophagus (LSBE) as compared with short segment Barrett's esophagus (SSBE). The aims of this study are to compare the frequency of esophageal function abnormalities between patients with LSBE and those with SSBE and to determine their clinical predictors. Methods This was a multicenter cohort study that included all patients with a diagnosis of BE who underwent high-resolution esophageal manometry. Motility disorders were categorized as hypercontractile disorders or hypocontractile disorders and their frequency was compared between patients with LSBE and those with SSBE. Multivariable logistic regression modeling was used to calculate the odds of being diagnosed with LSBE relative to SSBE for demographics, comorbidities, medication use, endoscopic findings, and the type of motility disorders. Results A total of 148 patients with BE were identified, of which 89 (60.1%) had SSBE and 59 (39.9%) LSBE. Patients with LSBE had a significantly larger hiatal hernia and higher likelihood of erosive esophagitis than patients with SSBE (P = 0.002). Patients with LSBE had a significantly lower mean LES resting pressure, distal contractile integral, distal latency, and significantly higher failed swallows and hypocontractile motility disorders than those with SSBE (P < 0.05). Hiatal hernia and hypocontractile motility disorder increased the odds of LSBE by 38.0% and 242.0%, as opposed to SSBE. Conclusions The presence of a hypocontractile motility disorder increased the risk for LSBE. Furthermore, the risk for LSBE was directly associated with the length of the hiatal hernia.
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Affiliation(s)
- Fahmi Shibli
- Department of Medicine, Division of Gastroenterology and Hepatology, Esophageal and Swallowing Center, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Ofer Z Fass
- Department of Medicine, Division of Gastroenterology and Hepatology, Stanford University, Stanford, CA, USA
| | - Oscar Matsubara Teramoto
- Department of Gastroenterology, ABC Medical Center PMG, Santa Fe, Contadero, Cuajimalpa de Morelos, Mexico
| | - José M Remes-Troche
- Deapartment of Digestive Physiology and Motility Laboratory, Medical Biological Research Institute, University of Veracruz, Veracruz, Mexico
| | - Vikram Rangan
- Department of Medicine, Division of Gastroenterology and Hepatology, Digestive Disease Center, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA, USA
| | - Michael Kurin
- Department of Medicine, Division of Gastroenterology and Hepatology, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Ronnie Fass
- Department of Medicine, Division of Gastroenterology and Hepatology, Esophageal and Swallowing Center, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
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Role of Obesity, Physical Exercise, Adipose Tissue-Skeletal Muscle Crosstalk and Molecular Advances in Barrett's Esophagus and Esophageal Adenocarcinoma. Int J Mol Sci 2022; 23:ijms23073942. [PMID: 35409299 PMCID: PMC8999972 DOI: 10.3390/ijms23073942] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 03/28/2022] [Accepted: 03/30/2022] [Indexed: 02/07/2023] Open
Abstract
Both obesity and esophageal adenocarcinoma (EAC) rates have increased sharply in the United States and Western Europe in recent years. EAC is a classic example of obesity-related cancer where the risk of EAC increases with increasing body mass index. Pathologically altered visceral fat in obesity appears to play a key role in this process. Visceral obesity may promote EAC by directly affecting gastroesophageal reflux disease and Barrett’s esophagus (BE), as well as a less reflux-dependent effect, including the release of pro-inflammatory adipokines and insulin resistance. Deregulation of adipokine production, such as the shift to an increased amount of leptin relative to “protective” adiponectin, has been implicated in the pathogenesis of BE and EAC. This review discusses not only the epidemiology and pathophysiology of obesity in BE and EAC, but also molecular alterations at the level of mRNA and proteins associated with these esophageal pathologies and the potential role of adipokines and myokines in these disorders. Particular attention is given to discussing the possible crosstalk of adipokines and myokines during exercise. It is concluded that lifestyle interventions to increase regular physical activity could be helpful as a promising strategy for preventing the development of BE and EAC.
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Mastracci L, Grillo F, Parente P, Unti E, Battista S, Spaggiari P, Campora M, Scaglione G, Fassan M, Fiocca R. Gastro-esophageal reflux disease and Barrett's esophagus: an overview with an histologic diagnostic approach. Pathologica 2021; 112:117-127. [PMID: 33179616 PMCID: PMC7931578 DOI: 10.32074/1591-951x-162] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 06/29/2020] [Indexed: 12/12/2022] Open
Abstract
The first part of this overview on non-neoplastic esophagus is focused on gastro-esophageal reflux disease (GERD) and Barrett’s esophagus. In the last 20 years much has changed in histological approach to biopsies of patients with gastro-esophageal reflux disease. In particular, elementary histologic lesions have been well defined and modality of evaluation and grade are detailed, their sensitivity and specificity has been evaluated and their use has been validated by several authors. Also if there is not a clinical indication to perform biopsies in patient with GERD, the diagnosis of microscopic esophagitis, when biopsies are provided, can be performed by following simple rules for evaluation which allow pathologists to make the diagnosis with confidence. On the other hand, biopsies are required for the diagnosis of Barrett’s esophagus. This diagnosis is the synthesis of endoscopic picture (which has to be provided with the proper description on extent and with adequate biopsies number) and histologic pattern. The current guidelines and expert opinions for the correct management of these diagnosis are detailed.
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Affiliation(s)
- Luca Mastracci
- Anatomic Pathology, San Martino IRCCS Hospital, Genova, Italy.,Anatomic Pathology, Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genova, Italy
| | - Federica Grillo
- Anatomic Pathology, San Martino IRCCS Hospital, Genova, Italy.,Anatomic Pathology, Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genova, Italy
| | - Paola Parente
- Unit of Pathology, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, (FG), Italy
| | - Elettra Unti
- UOC Anatomia Patologica, ARNAS Ospedali Civico-Di Cristina-Benfratelli, Palermo, Italy
| | - Serena Battista
- SOC di Anatomia Patologica, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Paola Spaggiari
- Department of Pathology, Humanitas Clinical and Research Center-IRCCS, Rozzano, Milan, Italy
| | - Michela Campora
- Anatomic Pathology, San Martino IRCCS Hospital, Genova, Italy
| | | | - Matteo Fassan
- Surgical Pathology Unit, Department of Medicine (DIMED), University of Padua, Italy
| | - Roberto Fiocca
- Anatomic Pathology, San Martino IRCCS Hospital, Genova, Italy.,Anatomic Pathology, Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genova, Italy
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Petrov RV, Fajardo RA, Bakhos CT, Abbas AE. Peroral endoscopic myotomy: techniques and outcomes. ACTA ACUST UNITED AC 2021; 5. [PMID: 34013165 DOI: 10.21037/shc.2020.02.02] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Achalasia is progressive neurodegenerative disorder of the esophagus, resulting in uncoordinated esophageal motility and failure of lower esophageal sphincter relaxation, leading to impaired swallowing. Surgical myotomy of the lower esophageal sphincter, either open or minimally invasive, has been a standard of care for the past several decades. Recently, new procedure-peroral endoscopic myotomy (POEM) has been introduced into clinical practice. This procedure accomplishes the same objective of controlled myotomy only via endoscopic approach. In the current chapter authors review the present state, clinical applications, outcomes and future directions of the POEM procedure.
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Affiliation(s)
- Roman V Petrov
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Romulo A Fajardo
- Department of General Surgery, Temple University Hospital. Philadelphia, PA, USA
| | - Charles T Bakhos
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Abbas E Abbas
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
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Clinical feasibility of a new antireflux ablation therapy on gastroesophageal reflux disease (with video). Gastrointest Endosc 2020; 92:1190-1201. [PMID: 32343977 DOI: 10.1016/j.gie.2020.04.046] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 04/09/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUNDS AND AIMS New mucosal resective and ablative endoscopic procedures based on gastric cardiac remodeling to prevent reflux have appeared. We aimed to evaluate the feasibility of a new ablative technique named antireflux ablation therapy (ARAT) for control of GERD in patients without hiatal hernia. METHODS Patients with proton pump inhibitor (PPI)-refractory GERD without hiatal hernia underwent ARAT between January 2016 and October 2019. Gastroesophageal Reflux Disease-Health-Related Quality of Life (GERD-HRQL), upper endoscopy, 24-hour pH monitoring, and PPI use were documented at 3, 6, 12, 24, and 36 months after ARAT. RESULTS One hundred eight patients were included (61 men [56.5%]; median age, 36.5 years; range, 18-78 years). ARAT was performed on all patients. At the 36-month evaluation, 84 patients had completed the protocol. Median ARAT time was 35.5 minutes (range, 22-51 minutes), and median circumference ablation was 300° (range, 270°-320°). No major adverse events occurred, and 14 of 108 patients (12.9%) presented with stenosis that was responsive to balloon dilation (<5 sessions). At the 3-month evaluation, the acid exposure time (AET), DeMeester score, and GERD-HRQL score had decreased from 18.8% to 2.8% (P = .001), 42.5 to 9.1 (P = .001), and 36.5 to 10 (P = .02), respectively, and these values were maintained up to 36 months. Success (AET <4%) was achieved in 89% and 72.2% at 3 and 36 months, respectively. Related factors at 36 months were as follows: pre-ARAT Hill type II (odds ratio [OR], 3.212; 95% confidence interval [CI], 1.431-5.951; P = .033), post-ARAT 3-month Hill type I (OR, 4.101; 95% CI, 1.812-9.121; P = .042), and AET <4% at 3 months (OR, 5.512; 95% CI, 1.451-7.621; P = .021). CONCLUSIONS ARAT is a feasible, safe, and effective therapy for early and mid-term treatment of GERD in patients without a sliding hiatal hernia. However, longer follow-up evaluations and randomized comparative studies are needed to clarify its real role. (Clinical trial registration number: NCT03548298.).
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Marques de Sá I, Marcos P, Sharma P, Dinis-Ribeiro M. The global prevalence of Barrett's esophagus: A systematic review of the published literature. United European Gastroenterol J 2020; 8:1086-1105. [PMID: 32631176 PMCID: PMC7724547 DOI: 10.1177/2050640620939376] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 06/04/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Determining the prevalence of Barrett's esophagus is important for defining screening strategies. We aimed to synthesize the available data, determine Barrett's esophagus prevalence, and assess variability. METHODS Three databases were searched. Subgroup, sensitivity, and meta-regression analyses were conducted and pooled prevalence was computed. RESULTS Of 3510 studies, 103 were included. In the general population, we estimated a prevalence for endoscopic suspicion of Barrett's esophagus of (a) any length with histologic confirmation of intestinal metaplasia as 0.96% (95% confidence interval: 0.85-1.07), (b) ≥1 cm of length with histologic confirmation of intestinal metaplasia as 0.96% (95% confidence interval: 0.75-1.18) and (c) for any length with histologic confirmation of columnar metaplasia as 3.89% (95% confidence interval: 2.25-5.54) . By excluding studies with high-risk of bias, the prevalence decreased to: (a) 0.70% (95% confidence interval: 0.61-0.79) and (b) 0.82% (95% confidence interval: 0.63-1.01). In gastroesophageal reflux disease patients, we estimated the prevalence with afore-mentioned criteria to be: (a) 7.21% (95% confidence interval: 5.61-8.81) (b) 6.72% (95% confidence interval: 3.61-9.83) and (c) 7.80% (95% confidence interval: 4.26-11.34). The Barrett's esophagus prevalence was significantly influenced by time period, region, Barrett's esophagus definition, Seattle protocol, and study design. There was a significant gradient East-West and North-South. There were minimal to no data available for several countries. Moreover, there was significant heterogeneity between studies. CONCLUSION There is a need to reassess the true prevalence of Barrett's esophagus using the current guidelines in most regions. Having knowledge about the precise Barrett's esophagus prevalence, diverse attitudes from educational to screening programs could be taken.
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Affiliation(s)
- Inês Marques de Sá
- Department of Gastroenterology, Portuguese Oncology Institute of
Porto, Porto, Portugal
| | - Pedro Marcos
- Department of Gastroenterology, Centro Hospitalar de Leiria,
Leiria, Portugal
| | - Prateek Sharma
- University of Kansas School of Medicine, Kansas City, USA
- Department of Gastroenterology, Veterans Affairs Medical Center,
Kansas City, USA
| | - Mário Dinis-Ribeiro
- Department of Gastroenterology, Portuguese Oncology Institute of
Porto, Porto, Portugal
- Center for Health Technology and Services Research (CINTESIS),
University of Porto, Porto, Portugal
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Wani S, Williams JL, Falk GW, Komanduri S, Muthusamy VR, Shaheen NJ. An Analysis of the GIQuIC Nationwide Quality Registry Reveals Unnecessary Surveillance Endoscopies in Patients With Normal and Irregular Z-Lines. Am J Gastroenterol 2020; 115:1869-1878. [PMID: 33156106 DOI: 10.14309/ajg.0000000000000960] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Population-based estimates of adherence to Barrett's esophagus (BE) guidelines are not available. Using a national registry, we assessed surveillance intervals for patients with normal and irregular Z-lines based on the presence or absence of intestinal metaplasia (IM) and among patients with suspected or confirmed BE. METHODS We analyzed data from the GI Quality Improvement Consortium Registry. Endoscopy data, including procedure indication, demographics, endoscopy and histology findings, and recommendations for further endoscopy, were assessed from January 2013 through December 2019. Patients with an indication of BE screening or surveillance or an endoscopic finding of BE were included. Biopsy and surveillance practices were assessed based on the length of columnar epithelium (0 cm, <1 cm, 1-3 cm, and >3 cm) and diagnosis based on histology findings. RESULTS A total of 1,907,801 endoscopies were assessed; 135,704 endoscopies (7.1%) performed in 114,894 patients met the inclusion criteria (men 61.4%, Whites 91%, and mean age of 61.7 years [SD 12.5]). Among patients with normal Z-lines, surveillance endoscopy was recommended for 81% of patients with IM and 20% of individuals without IM. Among patients with irregular Z-lines, surveillance endoscopy was recommended for 81% with IM and 24% without IM. Approximately 30% of patients with confirmed nondysplastic BE (lengths 1-3 and >3 cm) had recommended surveillance intervals of <3 years. DISCUSSION An analysis of data from a nationwide quality registry demonstrated that patients without BE are receiving recommendations for surveillance endoscopies and many patients with nondysplastic BE are reexamined too soon.
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Affiliation(s)
- Sachin Wani
- University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
| | | | - Gary W Falk
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Srinadh Komanduri
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | | | - Nicholas J Shaheen
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Fajardo RA, Petrov RV, Bakhos CT, Abbas AE. Endoscopic and Surgical Treatments for Achalasia: Who to Treat and How? Gastroenterol Clin North Am 2020; 49:481-498. [PMID: 32718566 PMCID: PMC7387747 DOI: 10.1016/j.gtc.2020.05.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Achalasia is a progressive neurodegenerative disorder characterized by failure of relaxation of the lower esophageal sphincter (LES) and altered motility of the esophagus. The traditional, highly effective, surgical approach to relieve obstruction at the LES includes cardiomyotomy. Fundoplication is added to decrease risk of postoperative reflux. Per oral endoscopic myotomy is a new endoscopic procedure that allows division of the LES via transoral route. It has several advantages including less invasiveness, cosmesis, and tailored approach to the length on the myotomy. However, it is associated with increased rate of post-procedural reflux. Various endoscopic interventions are used to address this problem.
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Affiliation(s)
- Romulo A. Fajardo
- Department of General Surgery, Temple University Hospital, Philadelphia, PA, USA, 3401 N Broad St, C-401, Philadelphia, PA 19140
| | - Roman V. Petrov
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA, 3401 N Broad St, C-501, Philadelphia, PA 19140
| | - Charles T. Bakhos
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA, 3401 N Broad St, C-501, Philadelphia, PA 19140
| | - Abbas E. Abbas
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA, 3401 N Broad St, C-501, Philadelphia, PA 19140
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Schlottmann F, Dreifuss NH, Patti MG. Obesity and esophageal cancer: GERD, Barrett´s esophagus, and molecular carcinogenic pathways. Expert Rev Gastroenterol Hepatol 2020; 14:425-433. [PMID: 32441160 DOI: 10.1080/17474124.2020.1764348] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Increases in the rates of esophageal adenocarcinoma (EAC) have paralleled rises in the prevalence of overweight and obesity. Despite not being fully understood, obesity-related EAC seems to have different carcinogenic pathways. AREAS COVERED This comprehensive review will thoroughly evaluate the current literature, describing the underlying mechanisms that help understanding the strong association between obesity and esophageal cancer. EXPERT COMMENTARY The risk of esophageal cancer among obese individuals could be partially explained by several factors: high prevalence of GERD; linear association between central adiposity and Barrett´s esophagus development; low levels of adiponectin and high levels of leptin that alter cell proliferation processes; insulin-resistant state that creates a tumorigenesis environment; and changes in the esophageal microbiota due to unhealthy dietary habits that promote carcinogenesis. In addition, a large proportion of obese patients are undergoing sleeve gastrectomy which can worsen GERD or cause de novo reflux, esophagitis, and Barrett´s metaplasia.
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Affiliation(s)
| | - Nicolás H Dreifuss
- Department of Surgery, Hospital Alemán of Buenos Aires , Buenos Aires, Argentina
| | - Marco G Patti
- Department of Medicine and Surgery, University of North Carolina , Chapel Hill, NC, USA
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12
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Inadomi JM. What's App with GERD? Gastroenterology 2020; 158:1211-1212. [PMID: 32004529 DOI: 10.1053/j.gastro.2020.01.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 01/23/2020] [Indexed: 12/02/2022]
Affiliation(s)
- John M Inadomi
- Division of Gastroenterology, Department of Medicine, University of Washington School of Medicine and Department of Health Services, University of Washington School of Public Health, Public Health Sciences Division, Fred Hutchinson Cancer Research Center.
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Parasa S, Desai M, Vittal A, Chandrasekar VT, Pervez A, Kennedy KF, Gupta N, Shaheen NJ, Sharma P. Estimating neoplasia detection rate (NDR) in patients with Barrett's oesophagus based on index endoscopy: a systematic review and meta-analysis. Gut 2019; 68:2122-2128. [PMID: 30872393 DOI: 10.1136/gutjnl-2018-317800] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 02/16/2019] [Accepted: 02/24/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Biopsies are obtained to confirm intestinal metaplasia and rule out prevalent dysplasia and cancer when Barrett's oesophagus (BE) is detected at index upper endoscopy (oesophagogastroduodenoscopy [EGD]). AIM The purpose of this systematic review was to obtain summary estimates of the prevalence of high-grade dysplasia (HGD) and oesophageal adenocarcinoma (EAC) associated with BE during index EGD for chronic GERD symptoms, defined as neoplasia detection rate (NDR) which could be used as a quality measure. METHODS An extensive search was performed within PUBMED, EMBASE and the Cochrane Library databases to identify studies in which patients underwent index endoscopy for the evaluation of the presence of BE. Two reviewers independently evaluated both the study eligibility and methodological quality and data extraction. A random-effects model (REM) based on the binomial distribution was used to calculate the pooled effects of the prevalence of BE-associated dysplasia and EAC. RESULTS For the calculation of dysplasia and EAC prevalence rates, a total of 11 studies with 10 632 patients met the inclusion criteria including 80.4% men with a mean age of 58.7 years and average BE length of 3.5 cm. The pooled prevalence of EAC, HGD and LGD was 3%(95% CI 2 to 5, 9 studies: 396/10 539 patients), 3%(95% CI 2 to 5 [REM], 9 studies: 388/10 539 patients) and 10%(95% CI 7 to 15 [REM], 10 studies: 907/8945 patients), respectively. For NDR, that is, the pooled prevalence of HGD/EAC was 7%(95% CI 4 to 10 [REM], 10 studies: 795/10 632 patients). CONCLUSION NDR is approximately 4% and could be used as a quality measure.
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Affiliation(s)
- Sravanthi Parasa
- Gastroenterology, Swedish Medical Group, Seattle, Washington, USA
| | - Madhav Desai
- Department of Gastroenterology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Anusha Vittal
- Department of Gastroenterology, KUMC, Kansas City, Kansas, USA
| | | | - Asad Pervez
- Department of Gastroenterology, KUMC, Kansas City, Kansas, USA
| | - Kevin F Kennedy
- Department of Gastroenterology, Kansas City VA Medical Center, Kansas City, Missouri, USA
| | - Neil Gupta
- Department of Gastroenterology, Loyola University Chicago Stritch School of Medicine, Maywood, Illinois, USA
| | - Nicholas J Shaheen
- Department of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Prateek Sharma
- Department of Gastroenterology, Kansas City VA Medical Center, Kansas City, Kansas, USA
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Why differences between New York and New Delhi matter in approach to gastroesophageal reflux disease. Indian J Gastroenterol 2019; 38:371-377. [PMID: 31768894 DOI: 10.1007/s12664-019-00987-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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15
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Reed CC, Shaheen NJ. Durability of Endoscopic Treatment for Dysplastic Barrett’s Esophagus. ACTA ACUST UNITED AC 2019; 17:171-186. [DOI: 10.1007/s11938-019-00226-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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16
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Pollit V, Graham D, Leonard C, Filby A, McMaster J, Mealing SJ, Lovat LB, Haidry RJ. A cost-effectiveness analysis of endoscopic eradication therapy for management of dysplasia arising in patients with Barrett's oesophagus in the United Kingdom. Curr Med Res Opin 2019; 35:805-815. [PMID: 30479169 DOI: 10.1080/03007995.2018.1552407] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND AND AIMS Endoscopic eradication therapy (EET) is the first line approach for treating Barrett's oesophagus (BE) related neoplasia globally. The British Society of Gastroenterology (BSG) recommend EET with combined endoscopic resection (ER) for visible dysplasia followed by endoscopic ablation in patients with both low and high grade dysplasia (LGD and HGD). The aim of this study is to perform a cost-effectiveness analysis for EET for treatment of all grades of dysplasia in BE patients. METHODS A Markov cohort model with a lifetime time horizon was used to undertake a cost-effectiveness analysis. A hypothetical cohort of UK patients diagnosed with BE entered the model. Patients in the treatment arm with LGD and HGD received EET and patients with non-dysplastic BE (NDBE) received endoscopic surveillance only. In the comparator arm, patients with LGD, HGD and NDBE received endoscopic surveillance only. A UK National Health Service (NHS) perspective was adopted and the incremental cost-effectiveness ratio (ICER) was calculated. Sensitivity analysis was conducted on key input parameters. RESULTS EET for patients with LGD and HGD arising in BE is cost-effective compared to endoscopic surveillance alone (lifetime ICER £3006 per quality adjusted life year [QALY] gained). The results show that, as the time horizon increases, the treatment becomes more cost-effective. The 5 year financial impact to the UK NHS of introducing EET is £7.1m. CONCLUSIONS EET for patients with low and high grade BE dysplasia, following updated guidelines from the BSG, has been shown to be cost-effective for patients with BE in the UK.
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Affiliation(s)
- Vicki Pollit
- a York Health Economics Consortium , York , United Kingdom
| | - David Graham
- b Department of Gastroenterology , University College London Hospital , United Kingdom
- c Division of Surgery and Science , University College London Hospital , United Kingdom
| | | | | | | | | | - Laurence B Lovat
- b Department of Gastroenterology , University College London Hospital , United Kingdom
- c Division of Surgery and Science , University College London Hospital , United Kingdom
| | - Rehan J Haidry
- b Department of Gastroenterology , University College London Hospital , United Kingdom
- c Division of Surgery and Science , University College London Hospital , United Kingdom
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Patel A, Gyawali CP. Screening for Barrett's Esophagus: Balancing Clinical Value and Cost-effectiveness. J Neurogastroenterol Motil 2019; 25:181-188. [PMID: 30827080 PMCID: PMC6474698 DOI: 10.5056/jnm18156] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 11/25/2018] [Accepted: 12/08/2018] [Indexed: 12/12/2022] Open
Abstract
In predisposed individuals with long standing gastroesophageal reflux disease (GERD), esophageal squamous mucosa can transform into columnar mucosa with intestinal metaplasia, commonly called Barrett’s esophagus (BE). Barrett’s mucosa can develop dysplasia, which can be a precursor for esophageal adenocarcinoma (EAC). However, most EAC cases are identified when esophageal symptoms develop, without prior BE or GERD diagnoses. While several gastrointestinal societies have published BE screening guidelines, these vary, and many recommendations are not based on high quality evidence. These guidelines are concordant in recommending targeted screening of predisposed individuals (eg, long standing GERD symptoms with age > 50 years, male sex, Caucasian race, obesity, and family history of BE or EAC), and against population based screening, or screening of GERD patients without risk factors. Targeted endoscopic screening programs provide earlier diagnosis of high grade dysplasia and EAC, and offer potential for endoscopic therapy, which can improve prognosis and outcome. On the other hand, endoscopic screening of the general population, unselected GERD patients, patients with significant comorbidities or patients with limited life expectancy is not cost-effective. New screening modalities, some of which do not require endoscopy, have the potential to reduce costs and expand access to screening for BE.
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Affiliation(s)
- Amit Patel
- Division of Gastroenterology, Duke University School of Medicine, and the Durham Veterans Affairs Medical Center, Durham, NC, USA
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St Louis, MO, USA
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Chatila AT, Nguyen MTT, Krill T, Roark R, Bilal M, Reep G. Natural history, pathophysiology and evaluation of gastroesophageal reflux disease. Dis Mon 2019; 66:100848. [PMID: 30803725 DOI: 10.1016/j.disamonth.2019.02.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Gastroesophageal reflux disease (GERD) is one of the most common diseases encountered by both internists and gastroenterologists. GERD can cause a wide variety of symptoms ranging from heartburn and regurgitation to more atypical symptoms such as cough, chest pain, and hoarseness. The diagnosis is often times made on the basis of history and clinical symptomatology. The prevalence of GERD is currently estimated to be 8-33% with the incidence of disease only expected to increase over time. Although most cases of GERD can be diagnosed based on symptoms and clinical presentation, the diagnosis of GERD can be challenging when symptoms are atypical. In this review, we provide a comprehensive summary of the epidemiology, pathophysiology, evaluation and diagnosis of gastroesophageal reflux disease.
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Affiliation(s)
- Ahmed T Chatila
- Department of Internal Medicine, The University of Texas Medical Branch, Galveston, TX, United States
| | - Minh Thu T Nguyen
- The University of Texas Medical Branch School of Medicine, Galveston, TX, United States
| | - Timothy Krill
- Division of Gastroenterology & Hepatology, The University of Texas Medical Branch, Galveston, TX, United States
| | - Russell Roark
- Department of Internal Medicine, The University of Texas Medical Branch, Galveston, TX, United States
| | - Mohammad Bilal
- Division of Gastroenterology & Hepatology, The University of Texas Medical Branch, Galveston, TX, United States.
| | - Gabriel Reep
- Division of Gastroenterology & Hepatology, The University of Texas Medical Branch, Galveston, TX, United States
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Al Salihi S, Jaitly V, Saulino DM, DuPont AW, Ertan A, Everett JM, Younes M. Pancreatic Acinar Metaplasia in Distal Esophageal Biopsies Is Associated With Chronic Nonsteroidal Anti-inflammatory Drug Use. Arch Pathol Lab Med 2018; 143:510-512. [PMID: 30525934 DOI: 10.5858/arpa.2018-0152-oa] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT.— The cause of pancreatic acinar metaplasia (PAM) at the distal esophagus/esophagogastric junction is still controversial. Whereas some authors believe it is congenital, others believe it is acquired because of inflammation of the gastric cardia, and more recently it was proposed to be due to chronic proton pump inhibitor use based on a study in rats. OBJECTIVE.— To determine whether there is correlation between chronic proton pump inhibitor use and PAM in humans. We also investigated the correlation between several clinical and pathologic factors and PAM. DESIGN.— Four hundred forty-four consecutive biopsies from the distal esophagus/esophagogastric junction were reviewed for the presence of PAM, which was then correlated with several clinical and pathologic findings. RESULTS.— Pancreatic acinar metaplasia was found in 71 patients (16%). Pancreatic acinar metaplasia was significantly associated with patient age younger than 51 years ( P < .001), chronic carditis ( P = .01), and chronic proton pump inhibitor use ( P = .008). Surprisingly, we also found significant association between PAM and chronic nonsteroidal anti-inflammatory drug use ( P < .001). These associations, including that with chronic nonsteroidal anti-inflammatory drug use, remained significant in multivariate analysis. CONCLUSIONS.— Our findings confirm the previous reports of significant association between PAM and chronic carditis and the findings from animal studies of association with chronic proton pump inhibitor use. The strong association with chronic nonsteroidal anti-inflammatory drug use has not been previously reported and warrants further studies.
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Affiliation(s)
- Suhair Al Salihi
- From the Department of Pathology and Laboratory Medicine (Drs Salihi, Jaitly, Saulino, Everett, and Younes) and the Department of Medicine, Section of Gastroenterology, Hepatology and Nutrition (Drs DuPont and Ertan), University of Texas Health Science Center at Houston McGovern Medical School and Memorial Hermann Hospital-TMC, Houston, Texas
| | - Vanya Jaitly
- From the Department of Pathology and Laboratory Medicine (Drs Salihi, Jaitly, Saulino, Everett, and Younes) and the Department of Medicine, Section of Gastroenterology, Hepatology and Nutrition (Drs DuPont and Ertan), University of Texas Health Science Center at Houston McGovern Medical School and Memorial Hermann Hospital-TMC, Houston, Texas
| | - David M Saulino
- From the Department of Pathology and Laboratory Medicine (Drs Salihi, Jaitly, Saulino, Everett, and Younes) and the Department of Medicine, Section of Gastroenterology, Hepatology and Nutrition (Drs DuPont and Ertan), University of Texas Health Science Center at Houston McGovern Medical School and Memorial Hermann Hospital-TMC, Houston, Texas
| | - Andrew W DuPont
- From the Department of Pathology and Laboratory Medicine (Drs Salihi, Jaitly, Saulino, Everett, and Younes) and the Department of Medicine, Section of Gastroenterology, Hepatology and Nutrition (Drs DuPont and Ertan), University of Texas Health Science Center at Houston McGovern Medical School and Memorial Hermann Hospital-TMC, Houston, Texas
| | - Atilla Ertan
- From the Department of Pathology and Laboratory Medicine (Drs Salihi, Jaitly, Saulino, Everett, and Younes) and the Department of Medicine, Section of Gastroenterology, Hepatology and Nutrition (Drs DuPont and Ertan), University of Texas Health Science Center at Houston McGovern Medical School and Memorial Hermann Hospital-TMC, Houston, Texas
| | - Jamie M Everett
- From the Department of Pathology and Laboratory Medicine (Drs Salihi, Jaitly, Saulino, Everett, and Younes) and the Department of Medicine, Section of Gastroenterology, Hepatology and Nutrition (Drs DuPont and Ertan), University of Texas Health Science Center at Houston McGovern Medical School and Memorial Hermann Hospital-TMC, Houston, Texas
| | - Mamoun Younes
- From the Department of Pathology and Laboratory Medicine (Drs Salihi, Jaitly, Saulino, Everett, and Younes) and the Department of Medicine, Section of Gastroenterology, Hepatology and Nutrition (Drs DuPont and Ertan), University of Texas Health Science Center at Houston McGovern Medical School and Memorial Hermann Hospital-TMC, Houston, Texas
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20
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Abstract
Endoscopic ablative therapy including radiofrequency ablation (RFA) represents the preferred management strategy for dysplastic Barrett's esophagus (BE) and appears to diminish the risk of developing esophageal adenocarcinoma (EAC). Limited data describe the natural history of the post-ablation esophagus. Recent findings demonstrate that recurrent intestinal metaplasia (IM) following RFA is relatively frequent. However, dysplastic BE and EAC subsequent to the complete eradication of intestinal metaplasia (CEIM) are uncommon. Moreover, data suggest that the risk of recurrent disease is probably highest in the first year following CEIM. Recurrent IM and dysplasia are usually successfully eradicated with repeat RFA. Future studies may refine surveillance intervals and inform the length of time surveillance should be conducted following RFA with CEIM. Further data will also be necessary to understand the utility of chemopreventive strategies, including NSAIDs, in reducing the risk of recurrent disease.
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Affiliation(s)
- Craig C Reed
- Center for Esophageal Diseases and Swallowing, and Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
- Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, 101 Manning Drive, Chapel Hill, NC, 27514, USA
| | - Nicholas J Shaheen
- Center for Esophageal Diseases and Swallowing, and Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA.
- University of North Carolina School of Medicine, CB#7080, Chapel Hill, NC, 27599-7080, USA.
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Gyawali CP, Kahrilas PJ, Savarino E, Zerbib F, Mion F, Smout AJPM, Vaezi M, Sifrim D, Fox MR, Vela MF, Tutuian R, Tack J, Bredenoord AJ, Pandolfino J, Roman S. Modern diagnosis of GERD: the Lyon Consensus. Gut 2018; 67:1351-1362. [PMID: 29437910 PMCID: PMC6031267 DOI: 10.1136/gutjnl-2017-314722] [Citation(s) in RCA: 788] [Impact Index Per Article: 131.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Revised: 01/11/2018] [Accepted: 01/14/2018] [Indexed: 12/12/2022]
Abstract
Clinical history, questionnaire data and response to antisecretory therapy are insufficient to make a conclusive diagnosis of GERD in isolation, but are of value in determining need for further investigation. Conclusive evidence for reflux on oesophageal testing include advanced grade erosive oesophagitis (LA grades C and D), long-segment Barrett's mucosa or peptic strictures on endoscopy or distal oesophageal acid exposure time (AET) >6% on ambulatory pH or pH-impedance monitoring. A normal endoscopy does not exclude GERD, but provides supportive evidence refuting GERD in conjunction with distal AET <4% and <40 reflux episodes on pH-impedance monitoring off proton pump inhibitors. Reflux-symptom association on ambulatory reflux monitoring provides supportive evidence for reflux triggered symptoms, and may predict a better treatment outcome when present. When endoscopy and pH or pH-impedance monitoring are inconclusive, adjunctive evidence from biopsy findings (histopathology scores, dilated intercellular spaces), motor evaluation (hypotensive lower oesophageal sphincter, hiatus hernia and oesophageal body hypomotility on high-resolution manometry) and novel impedance metrics (baseline impedance, postreflux swallow-induced peristaltic wave index) can add confidence for a GERD diagnosis; however, diagnosis cannot be based on these findings alone. An assessment of anatomy, motor function, reflux burden and symptomatic phenotype will therefore help direct management. Future GERD management strategies should focus on defining individual patient phenotypes based on the level of refluxate exposure, mechanism of reflux, efficacy of clearance, underlying anatomy of the oesophagogastric junction and psychometrics defining symptomatic presentations.
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Affiliation(s)
- C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Peter J Kahrilas
- Division of Gastroenterology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Edoardo Savarino
- Division of Gastroenterology, Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, Padua, Italy
| | - Frank Zerbib
- Department of Gastroenterology, Bordeaux University Hospital, Université de Bordeaux, Bordeaux, France
| | - Francois Mion
- Digestive Physiology, Hopital E Herriot, Hospices Civils de Lyon, Université de Lyon, Lyon, France,Digestive Physiology, Université de Lyon, Lyon I University, Lyon, France,Université de Lyon, Inserm U1032, Lyon, France
| | - André J P M Smout
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Michael Vaezi
- Division of Gastroenterology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Daniel Sifrim
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Mark R Fox
- Gastroenterology, St. Claraspital, Kleinriehenstrasse 30, Basel, Switzerland,Zürich Neurogastroenterology and Motility Research Group, Clinic for Gastroenterology and Hepatology, University Hospital of Zürich, Zürich, Switzerland
| | - Marcelo F Vela
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Radu Tutuian
- Division of Gastroenterology, University Clinics for Visceral Surgery and Medicine, Bern University Hospital, Bern, Switzerland
| | - Jan Tack
- Department of Gastroenterology, Catholic University of Leuven, Leuven, Belgium
| | - Albert J Bredenoord
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - John Pandolfino
- Division of Gastroenterology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Sabine Roman
- Digestive Physiology, Hopital E Herriot, Hospices Civils de Lyon, Université de Lyon, Lyon, France,Digestive Physiology, Université de Lyon, Lyon I University, Lyon, France,Université de Lyon, Inserm U1032, Lyon, France
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23
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Transoral incisional fundoplication for reflux after peroral endoscopic myotomy: a crucial addition to our arsenal. Endosc Int Open 2018; 6:E549-E552. [PMID: 29756011 PMCID: PMC5943699 DOI: 10.1055/a-0584-6802] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 02/05/2018] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Increased esophageal acid exposure is seen in a large percentage of patients with achalasia who undergo peroral endoscopic myotomy (POEM). Endoscopic transoral fundoplication (TIF) is a novel endoscopic technique for the management of patients with chronic gastroesophageal reflux (GERD). We present the first case series evaluating the role of TIF post-POEM. METHODS Consecutive patients 18 years or older from our academic institution who underwent a POEM procedure and subsequently underwent TIF for symptomatic reflux or regurgitation between December 2014 and June 2017 were included. The primary outcome was discontinuation of proton-pump inhibitor (PPI) use and healing of esophagitis (when initially present) on post-procedure esophagogastroduodenoscopy (EGD). Technical success was defined as successful completion of the endoscopic fundoplication. Adverse events (AEs) were recorded for all patients. RESULTS Five patients were included (60 % male, average age 55 ± 14 years). Technical success was achieved in 100 % of patients. Discontinuation of PPI use was achieved in 5/5 patients (100 %). Three patients had esophagitis pre-procedure and all were noted to have resolution of inflammation on post-procedure EGD. No adverse events were noted. Mean follow-up time was 27 months (range 5 - 34 months). CONCLUSION TIF post-POEM appears feasible, safe, and efficacious in improving symptoms and esophagitis, decreasing long-term risks of acid exposure, and decreasing risks of long-term PPI use in patients post-POEM in this small cohort of patients. Larger studies are needed to confirm these initial findings.
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Abstract
BACKGROUND Gastroesophageal reflux disease (GERD) affects an estimated 20% of the population in the USA, and its prevalence is increasing worldwide. About 10-15% of patients with GERD will develop Barrett's esophagus (BE). AIMS The aims of this study were to review the available evidence of the pathophysiology of BE and the role of anti-reflux surgery in the treatment of this disease. RESULTS The transformation of the squamous epithelium into columnar epithelium with goblet cells is due to the chronic injury produced by repeated reflux episodes. It involves genetic mutations that in some patients may lead to high-grade dysplasia and cancer. There is no strong evidence that anti-reflux surgery is associated with resolution or improvement in BE, and its indications should be the same as for other GERD patients without BE. CONCLUSIONS Patients with BE without dysplasia require endoscopic surveillance, while those with low- or high-grade dysplasia should have consideration of endoscopic eradication therapy followed by surveillance. New endoscopic treatment modalities are being developed, which hold the promise to improve the management of patients with BE.
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Care of the Postablation Patient: Surveillance, Acid Suppression, and Treatment of Recurrence. Gastrointest Endosc Clin N Am 2017; 27:515-529. [PMID: 28577772 DOI: 10.1016/j.giec.2017.02.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Endoscopic eradication therapy is effective and durable for the treatment of Barrett's esophagus (BE), with low rates of recurrence of dysplasia but significant rates of recurrence of intestinal metaplasia. Identified risk factors for recurrence include age and length of BE before treatment and may also include presence of a large hiatal hernia, higher grade of dysplasia before treatment, and history of smoking. Current guidelines for surveillance following ablation are limited, with recommendations based on low-quality evidence and expert opinion. New modalities including optical coherence tomography and wide-area tissue sampling with computer-assisted analysis show promise as adjunctive surveillance modalities.
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ACG Clinical Guideline: Diagnosis and Management of Barrett's Esophagus. Am J Gastroenterol 2016; 111:30-50; quiz 51. [PMID: 26526079 DOI: 10.1038/ajg.2015.322] [Citation(s) in RCA: 991] [Impact Index Per Article: 123.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Accepted: 08/28/2015] [Indexed: 12/11/2022]
Abstract
Barrett's esophagus (BE) is among the most common conditions encountered by the gastroenterologist. In this document, the American College of Gastroenterology updates its guidance for the best practices in caring for these patients. These guidelines continue to endorse screening of high-risk patients for BE; however, routine screening is limited to men with reflux symptoms and multiple other risk factors. Acknowledging recent data on the low risk of malignant progression in patients with nondysplastic BE, endoscopic surveillance intervals are attenuated in this population; patients with nondysplastic BE should undergo endoscopic surveillance no more frequently than every 3-5 years. Neither routine use of biomarker panels nor advanced endoscopic imaging techniques (beyond high-definition endoscopy) is recommended at this time. Endoscopic ablative therapy is recommended for patients with BE and high-grade dysplasia, as well as T1a esophageal adenocarcinoma. Based on recent level 1 evidence, endoscopic ablative therapy is also recommended for patients with BE and low-grade dysplasia, although endoscopic surveillance continues to be an acceptable alternative. Given the relatively common recurrence of BE after ablation, we suggest postablation endoscopic surveillance intervals. Although many of the recommendations provided are based on weak evidence or expert opinion, this document provides a pragmatic framework for the care of the patient with BE.
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Al-Haddad S, Chang AC, De Hertogh G, Grin A, Langer R, Sagaert X, Salemme M, Streutker CJ, Soucy G, Tripathi M, Upton MP, Vieth M, Villanacci V. Adenocarcinoma at the gastroesophageal junction. Ann N Y Acad Sci 2014; 1325:211-25. [DOI: 10.1111/nyas.12535] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Sahar Al-Haddad
- Department of Laboratory Medicine and Pathobiology; St. Michael's Hospital; Toronto Canada
| | - Andrew C. Chang
- Section of Thoracic Surgery; University of Michigan Medical Center; Ann Arbor Michigan
| | - Gert De Hertogh
- Department of Morphology and Molecular Pathology; University Hospitals of K.U. Leuven; Leuven Belgium
| | | | - Rupert Langer
- Institute of Pathology; University of Bern; Bern Switzerland
| | - Xavier Sagaert
- Department of Morphology and Molecular Pathology; University Hospitals of K.U. Leuven; Leuven Belgium
| | | | - Catherine J. Streutker
- Department of Laboratory Medicine and Pathobiology; St. Michael's Hospital; Toronto Canada
| | - Geneviève Soucy
- Département de Pathologie - Pathologie Gastro-intestinale; Centre Hospitalier de l'Université de Montréal; Montréal Canada
| | - Monika Tripathi
- Department of Cellular Pathology; Oxford University Hospitals NHS Trust; Oxford United Kingdom
| | - Melissa P. Upton
- Department of Pathology; University of Washington; Seattle Washington
| | - Michael Vieth
- Institute of Pathology; Klinikum Bayreuth; Bayreuth Germany
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Lind A, Koenderman L, Kusters JG, Siersema PD. Squamous tissue lymphocytes in the esophagus of controls and patients with reflux esophagitis and Barrett's esophagus are characterized by a non-inflammatory phenotype. PLoS One 2014; 9:e106261. [PMID: 25170842 PMCID: PMC4149547 DOI: 10.1371/journal.pone.0106261] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2013] [Accepted: 08/03/2014] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Reflux esophagitis (RE) is characterized by inflammation of the squamous epithelium (SQ) of the esophagus and may progress to Barrett's esophagus (BE) characterized by intestinal metaplasia. The role of inflammation in this transition has been postulated but lacks experimental evidence. Here, the inflammatory responses in the esophagus of these patients were investigated. PATIENTS AND METHODS Fifty-one esophageal biopsies from with patients BE (n = 19), RE (n = 8) and controls (n = 23) were analyzed. T-cells were analyzed before and after ex vivo expansion (14 days) by multicolor flow cytometric analysis. The following markers were studied: CD3, CD4, CD8 (T-cell markers), Granzyme B (marker of cytotoxicity), CD103 (αE/epithelial integrin) and NKg2a (inhibitory receptor on T-cells and NK-cells). RESULTS Analysis of ex vivo cultures from normal looking SQ from controls, RE patients, and BE patients revealed no significant differences in the number and phenotypes of T-cells. In contrast, tissue from RE was different to normal SQ in four aspects: 1) higher percentages of CD3+ CD4+-cells (72±7% vs 48±6%, p = 0.01) and 2) CD8+ GranzymeB+-cells (53±11% vs 26±4%, p<0.05), while 3) lower percentages of CD4+ CD103+-cells (45±19% vs 80±3%, p = 0.02) and 4) CD8+ NKg2a+-cells (31±12% vs 44±5%). CONCLUSION Despite the fact that both tissues are exposed to the same reflux associated inflammatory triggers, the immune response observed in RE is clearly distinct from that in SQ of BE. The differences in immune responses in BE tissue might contribute to its susceptibility for transformation into intestinal metaplasia.
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Affiliation(s)
- Alexandra Lind
- Department of Respiratory Medicine, University Medical Center Utrecht, Utrecht, the Netherlands
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Leo Koenderman
- Department of Respiratory Medicine, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Johannes G. Kusters
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Peter D. Siersema
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, the Netherlands
- * E-mail:
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Bronner MP. Barrett's Esophagus. THE KOREAN JOURNAL OF HELICOBACTER AND UPPER GASTROINTESTINAL RESEARCH 2014. [DOI: 10.7704/kjhugr.2014.14.3.131] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Mary P. Bronner
- Division of Anatomic Pathology & Molecular Oncology, University of Utah and ARUP Laboratories, Huntsman Cancer Institute, Salt Lake City, UT, USA
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Pancreatic acinar cells--a normal finding at the gastroesophageal junction? Data from a prospective Central European multicenter study. Virchows Arch 2013; 463:643-50. [PMID: 23989798 DOI: 10.1007/s00428-013-1471-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2013] [Revised: 07/28/2013] [Accepted: 08/06/2013] [Indexed: 02/06/2023]
Abstract
Pancreatic acinar cells are a well-recognized finding at the gastroesophageal junction, but their histogenesis and biological significance are unclear. From the prospective Central European multicenter histoGERD trial, we recruited 1,071 individuals undergoing gastroscopy for various non-selected reasons. Biopsy material was systematically sampled from the gastroesophageal junction and from the stomach. The study aimed to assess the prevalence of pancreatic acinar cells and to relate their presence to various histologic and clinical features. Overall, pancreatic acinar cells were observed in 184 (17.2%) participants. Individuals diagnosed with pancreatic acinar cells were slightly younger than those without (median 50 vs. 53 years; p = 0.009). There was no association with patients' symptoms and/or complaints or with an endoscopic diagnosis of esophagitis or Barrett's esophagus. Regarding histology, pancreatic acinar cells were not associated with features of the squamous epithelium indicating reflux disease, such as basal cell hyperplasia, papillary elongation, dilation of intercellular spaces, and inflammatory cell number, but were associated with the presence of cardiac mucosa (p < 0.001), oxyntocardiac mucosa (p < 0.001), and intestinal metaplasia (p = 0.038), respectively. No association with Helicobacter pylori infection or diagnosis of gastritis was noted. In conclusion, pancreatic acinar cells are a common finding at the gastroesophageal junction, and no association with either reflux disease (histologically or endoscopically) or diagnosis of gastritis was observed. These data suggest a congenital rather than an acquired (metaplastic) origin of pancreatic acinar cells at the gastroesophageal junction. This questions the term "pancreatic acinar metaplasia" which is currently widely used for their diagnosis.
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Meyer HJ. [Clinical aspects of premalignant lesions of the upper gastrointestinal tract]. DER PATHOLOGE 2011; 32 Suppl 2:202-5. [PMID: 21837400 DOI: 10.1007/s00292-011-1471-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
A variety of somatic genetic and epigenetic aberrations are discussed in the multistep carcinogenesis of tumors of the upper gastrointestinal tract but specific genetic changes are still unknown. Primary prevention of cancer is important and includes the control of causal endo- and exogenous factors. Screening endoscopies to detect premalignant lesions or early carcinoma cannot be recommended in the Western world. The incidence of preinvasive neoplasia, above all the high-grade intraepithelial neoplasia, in Barrett's esophagus or stomach is as low as 4.0 or 0.6%, respectively. Secondary prevention of cancer after changes of the mucosa should be performed by endoscopic diagnosis and treatment performing biopsies or resection of the lesion. After histological diagnosis of a high-grade intraepithelial neoplasia, complete resection of these lesions including complete ablation of Barrett's mucosa should be carried out. On the basis of an exact pathological report, close cooperation between endoscopist and surgeon seems to be necessary to find out the best individual therapy with curative intent.
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Affiliation(s)
- H-J Meyer
- Klinik für Allgemein- und Viszeralchirurgie, Städtisches Klinikum Solingen gGmbH, Gotenstr. 1, 42653, Solingen, Deutschland.
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Taylor JB, Rubenstein JH. Meta-analyses of the effect of symptoms of gastroesophageal reflux on the risk of Barrett's esophagus. Am J Gastroenterol 2010; 105:1729, 1730-7; quiz 1738. [PMID: 20485283 PMCID: PMC2916949 DOI: 10.1038/ajg.2010.194] [Citation(s) in RCA: 92] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Esophageal adenocarcinoma (EAC) is a devastating disease that has risen in incidence over the past several decades. Barrett's esophagus (BE) is an associated premalignant lesion. Current preventative efforts rely on endoscopic screening of individuals with gastroesophageal reflux disease (GERD) symptoms and surveillance endoscopy for those with BE. However, some recent studies have found a high prevalence of BE in patients without GERD, and others have found little or no association with GERD. We hypothesized that studies of higher-quality design show weaker associations of GERD with BE, and that GERD is only weakly associated with short-segment Barrett's esophagus (SSBE). METHODS We performed a systematic literature search in multiple online electronic databases regardless of language. Eligible studies required visualization of columnar mucosa and histological confirmation of intestinal metaplasia, and GERD symptoms ascertained by questionnaire or interview. The highest-quality sampling design was defined a priori by both cases and controls identified among unselected research volunteers ("research design") rather than by patients selected for endoscopy for clinical indications ("clinical design"), which introduces selection and ascertainment bias. A priori, heterogeneity was defined by Cochrane's Q P<0.20 and the inconsistency index (I(2); 25% low, 50% moderate, and 75% high). Heterogeneity of results can reflect significant differences in study design or effect modification by strata of outcomes. RESULTS Systematic review identified 13,392 citations. Evaluation identified 108 potentially relevant journal articles, of which 26 met eligibility. Of these, 14 studies identified cases of BE and controls based on clinical indication ("clinical design"), and 6 used the "research design." The remaining six studies identified cases of BE from patients undergoing endoscopy for clinical indication and controls among patients without known BE ("cases clinical/controls research"). The summary odds ratio (OR) for the association of GERD with BE from all studies was 2.90 (95% confidence interval (CI), 1.86-4.54), but the results were very heterogeneous (P=0.0001; I(2)=89%). When stratified by BE length and sampling design, the studies with clinical design showed substantial, but heterogeneous, associations with SSBE (OR, 2.38; 95% CI, 1.21-4.70; P=0.02; I(2)=62%), and stronger and homogeneous association with long-segment BE (LSBE; fixed effects OR, 2.96; 95% CI, 1.69-5.19; P=0.25; I(2)=25%). In the research study design, stratifying by length of BE resolved the heterogeneity and showed a strong association between GERD and LSBE (fixed effects OR, 4.92; 95% CI, 2.01-12.0; P=0.30; I(2)=19%) and no association with SSBE (fixed effects OR, 1.15; 95% CI, 0.763-1.73; P=0.84; I(2)=0%). Funnel plots showed potential evidence for bias against dissemination of small negative studies. CONCLUSIONS In the highest-quality studies, GERD symptoms are not associated with SSBE, but increased the odds of LSBE by fivefold. GERD symptoms can serve as a reliable predictor of LSBE, but not SSBE. If SSBE is considered worthy of identification, then current screening practices do not select patients at risk for endoscopy, and alternative methods of selection for screening need to be developed.
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Affiliation(s)
- Justin B. Taylor
- Michigan Institute for Clinical and Health Research, Ann Arbor, Michigan, USA
| | - Joel H. Rubenstein
- Veterans Affairs Center of Excellence for Clinical Management Research, Ann Arbor, Michigan, USA
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
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Pancreatic acinar metaplasia in the distal oesophagus and the gastric cardia: prevalence, predictors and relation to GORD. J Gastroenterol 2010; 45:291-9. [PMID: 20012917 DOI: 10.1007/s00535-009-0161-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2009] [Accepted: 11/01/2009] [Indexed: 02/04/2023]
Abstract
PURPOSE The nature of pancreatic acinar metaplasia (PAM) in the gastro-oesophageal junction (GOJ) remains obscure. We aimed to estimate its prevalence and investigate into its risk factors in a population-based series of first-time endoscopy patients. METHODS We investigated consecutive patients, endoscoped for the first time, representing defined catchment area populations. Biopsies were taken immediately below the GOJ and from the distal oesophagus. Endoscopy room-based cross-sectional clinical data were supplemented with exposure data from 160 population controls. Associations, expressed as odds ratios (OR), were modelled with multivariable logistic regression. A subsample of 26 patients underwent oesophageal pH monitoring. RESULTS Among 644 patients (mean age 53 years, 43% men), PAM was found in 121 patients (19%), exclusively above the GOJ in 40 (6%), below GOJ in 67 (10%), and both above and below GOJ in 14 (2%). PAM exclusively above the GOJ and PAM exclusively below the GOJ were both borderline associated with age (2% increase in prevalence per year). PAM exclusively above the GOJ was significantly associated with female gender (OR 2.8, 95% CI 1.3-6.3) and presence of Helicobacter pylori immediately below the GOJ (OR 2.6, 95% CI 1.3-5.4). Out of 21 patients with Barrett's oesophagus (BO), 8 (38%) had PAM above the GOJ. The mean value for percentage time with oesophageal pH < 4.0 was 7.3% (95% CI 4.3-10.2%) among patients who had PAM above the GOJ (reference value 3.4%). CONCLUSIONS Pancreatic acinar metaplasia might be an age-dependent lesion, associated with H. pylori, female gender and gastro-oesophageal reflux if located above the GOJ.
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34
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Barrett's esophagus: Size of the problem and diagnostic value of a novel histopathology classification. Eur Surg 2009. [DOI: 10.1007/s10353-009-0446-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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35
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Histopathology of the endoscopic esophagogastric junction in patients with gastroesophageal reflux disease. Wien Klin Wochenschr 2008; 120:350-9. [DOI: 10.1007/s00508-008-0997-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2007] [Accepted: 05/06/2008] [Indexed: 12/20/2022]
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36
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Lenglinger J, Ringhofer C, Eisler M, Sedivy R, Wrba F, Zacherl J, Cosentini EP, Prager G, Haefner M, Riegler M. Histopathology of columnar-lined esophagus in patients with gastroesophageal reflux disease. Wien Klin Wochenschr 2007; 119:405-11. [PMID: 17671821 DOI: 10.1007/s00508-007-0825-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2007] [Accepted: 04/18/2007] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND AIMS The question of whether an endoscopically normal-appearing esophagogastric junction should be biopsied in patients with gastroesophageal reflux disease is controversial. We have addressed this issue using endoscopy and histopathology. METHODS A total of 114 consecutive patients (58 males) with symptoms of gastroesophageal reflux disease prospectively underwent endoscopy, including biopsy sampling from the esophagogastric junction. Endoscopically visible columnar-lined esophagus was defined by the presence of gastric-type mucosa above the level of the rise of the gastric folds. Histopathology was conducted using the Paull-Chandrasoma classification. RESULTS Of the 114 patients, 85 (74.6%) had endoscopically visible columnar-lined esophagus of length < or =0.5 cm (n = 82), 1 cm (n = 2) and 7 cm (n = 1); 29 patients (25.4%) had a normal endoscopic junction. All patients had histopathologic columnar-lined esophagus. Intestinal metaplasia and low-grade dysplasia was identified in 26 (22.8%) and 5 (4.4%) individuals, respectively, and was not statistically different in endoscopically normal vs. abnormal junction (P = 0.408 for intestinal metaplasia, P = 0.775 for low grade dysplasia). Intestinal metaplasia was independent from endoscopic esophagitis (P = 0.398) and hiatal hernia (P = 0.405). CONCLUSIONS Columnar-lined esophagus cannot be excluded by endoscopy. In patients with gastroesophageal reflux disease, biopsy sampling of normal-appearing junction is recommended for histopathologic exclusion of intestinal metaplasia and low-grade dysplasia.
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Affiliation(s)
- Johannes Lenglinger
- University Clinic of Surgery, Medical University Vienna, Währinger Gürtel 18-20, Vienna, Austria.
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37
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Johansson J, Håkansson HO, Mellblom L, Kempas A, Granath F, Johansson KE, Nyrén O. Diagnosing Barrett's oesophagus: factors related to agreement between endoscopy and histology. Eur J Gastroenterol Hepatol 2007; 19:870-7. [PMID: 17873611 DOI: 10.1097/meg.0b013e3282cf5018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND AND STUDY AIM Few previous studies have addressed the agreement between endoscopy and histology regarding Barrett's oesophagus in unselected endoscopy patients. Our aim was to quantify this agreement, and to study its relation to clinical and endoscopic characteristics in consecutive patients coming for first-time gastroscopy. METHODS We invited consecutive patients aged 18-79 years and endoscoped for the first time at endoscopy units exclusively serving defined catchment areas in southeast Sweden. Endoscopic and clinical data were recorded according to a predetermined protocol, and biopsies were taken from the distal oesophagus in all patients. RESULTS Among 705 patients included, 17% [95% confidence interval (CI): 14-20] had endoscopically visible columnar mucosa above the oesophagogastric junction and 38% (95% CI: 34-42) had columnar mucosa in at least one biopsy irrespective of the endoscopic finding. The overall concordance between endoscopy and histology regarding presence (or absence) of columnar mucosa above the oesophagogastric junction was 74% (95% CI: 71-77) and the agreement beyond chance, as measured by Kappa (kappa) statistics, was fair, kappa=0.38 (95% CI: 0.32-0.45). The agreement between the endoscopic assessment and intestinal metaplasia at biopsy was 86% (95% CI: 83-88), but kappa was only 0.31 (95% CI: 0.21-0.41). Our data were consistent with a lower threshold for macroscopic detection of columnar epithelium above the oesophagogastric junction, when risk factors for Barrett's oesophagus were present. CONCLUSION The agreement between macroscopic and microscopic assessments of Barrett's oesophagus is no more than fair, and partly dependent on the presence of patient characteristics suggestive of pathology in this region.
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Affiliation(s)
- Johan Johansson
- Department of Surgery, Kalmar County Hospital, Stockholm, Sweden.
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38
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El-Serag HB, Graham DY, Rabeneck L, Avid A, Richardson P, Genta RM. Prevalence and determinants of histological abnormalities of the gastric cardia in volunteers. Scand J Gastroenterol 2007; 42:1158-66. [PMID: 17852849 DOI: 10.1080/00365520701299915] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The findings of studies examining the prevalence and major risk factors of histological abnormalities of the gastric cardia have been inconsistent. Selection bias was possible in these studies depending on whether patients were referred for ulcer or gastroesophageal reflux disease (GERD). There have been no studies on non-patient populations. The aim of this study was to mitigate the potential effects of selection bias. MATERIAL AND METHODS In a study comprising health-care workers, we distributed symptom questionnaires and invitations to undergo upper endoscopy. A single endoscopist performed standard endoscopy and biopsy examinations (2 antral, 2 corporal, and 2 cardiac biopsies). Staining was done using triple stain. Two pathologists, who were blinded to the results of the questionnaires and endoscopy, interpreted and recorded the histological findings. RESULTS A total of 226 participants underwent endoscopy. Gastric cardia, as defined by the presence of mucous glands, was identified in 191 subjects; mean age of the subjects was 45 years, 117 (61%) were women, and 49% were black. Active gastritis of the cardia was present in 58 (30.4%), chronic gastritis in 133 (69.6%), intestinal metaplasia (IM) in 29 (15.2%), and pancreatic metaplasia in 25 (13%). Direct (organisms) or indirect evidence (active anywhere or chronic gastritis in antrum or corpus) for Helicobacter pylori was present in all participants with active gastritis, 60% of subjects with chronic gastritis, and approximately half of those with IM of the cardia. Approximately 15% with chronic carditis had neither H. pylori nor GERD symptoms. There were also no significant differences in the prevalence of heartburn or acid regurgitation, or the use of histamine-2-receptor antagonists (H2RAs) or proton-pump inhibitors (PPIs) between groups with and without active or chronic gastritis, IM, or pancreatic metaplasia, whereas active or chronic gastritis in the antrum or corpus and H. pylori infection were more frequent (1.5- to 2-fold) among those with histological abnormalities of the cardia. CONCLUSIONS Active and chronic gastritis as well as intestinal metaplasia of the gastric cardia are relatively common in health-care worker volunteers. Although GERD symptoms are not significantly associated with these abnormalities, H. pylori infection is a strong risk factor. However, a considerable number of participants with chronic gastritis of the cardia have neither H. pylori nor GERD.
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Affiliation(s)
- Hashem B El-Serag
- Section of Gastroenterology, Houston Department of Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas, USA.
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Ochs-Balcom HM, Falk G, Grady WM, Kinnard M, Willis J, Elston R, Eng C, Chak A. Consortium approach to identifying genes for Barrett's esophagus and esophageal adenocarcinoma. Transl Res 2007; 150:3-17. [PMID: 17585859 DOI: 10.1016/j.trsl.2007.02.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2007] [Revised: 02/21/2007] [Accepted: 02/23/2007] [Indexed: 11/29/2022]
Abstract
Consortium approaches are becoming increasingly more common for a variety of chronic diseases and conditions. The Familial Barrett's Esophagus Consortium began in 1998 and was originally designed to investigate the evidence for familial aggregation of Barrett's esophagus, esophageal adenocarcinoma, or esophagogastric junctional adenocarcinoma. The authors have shown that this phenotype does in fact aggregate in families; therefore, linkage analyses are currently underway. The Consortium, whose goals and membership are growing, has been successfully established and maintained. In this article, details about the research design and membership are provided, as are the current and future goals of the Consortium. The authors believe that this time is especially exciting for research in this area, and they look forward to answering more questions relevant to these diseases with regard to both genetic and environmental risk factors to ultimately design more effective treatment and prevention strategies.
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Affiliation(s)
- Heather M Ochs-Balcom
- Department of Epidemiology and Biostatistics, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
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Ringhofer C, Lenglinger J, Eisler M, Wrba F, Sedivy R, Zacherl J, Cosentini EP, Prager G, Devyatko E, Riegler M. Videoendoscopy and histopathology of the esophagogastric junction in patients with gastroesophageal reflux disease. Wien Klin Wochenschr 2007; 119:283-90. [PMID: 17571232 DOI: 10.1007/s00508-007-0786-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2006] [Accepted: 11/21/2006] [Indexed: 01/11/2023]
Abstract
BACKGROUND AND AIMS During endoscopy the stomach is considered to rise at the level of the 'gastric' folds; however, anatomical studies have demonstrated that the proximal gastric folds may in fact be esophageal. This prospective study was designed to assess the histopathology of endoscopically visible proximal gastric folds in patients with gastroesophageal reflux disease. METHODS 35 consecutive patients (20 males) with gastroesophageal reflux disease underwent video endoscopy, including biopsy sampling from the endoscopically visible esophagogastric junction (0 cm, 0.5 cm and 1.0 cm distal to the rise of gastric folds and 0.5 cm and 1.0 cm proximal to it). Endoscopy was digitally recorded and reviewed for assignment of biopsy level. Columnar-lined esophagus and esophagitis were cataloged according to the Paull-Chandrasoma histopathologic classification and the Los Angeles endoscopic classification. RESULTS Endoscopy: Normal endoscopic esophagogastric junction was seen in 11 (31%) patients and visible columnar-lined esophagus < or = 0.5 cm in 24 (69%). HISTOLOGY Columnar-lined esophagus extended 1.0 cm in 22.8% of patients and 0.5 cm in 51.4%, distal to the rise of the gastric folds. In all patients columnar-lined esophagus was interposed between squamous epithelium and gastric oxyntic mucosa. Thus, so-called gastric folds contained mucosa of esophageal origin in all patients. Intestinal metaplasia (Barrett esophagus) was detected in eight (22.9%) patients. CONCLUSIONS Endoscopy cannot exclude histopathologic columnar-lined esophagus within gastric rugae. Thus, visible 'gastric' folds should not be used for definition of the esophagogastric junction but as a reference landmark for biopsy sampling during endoscopy.
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Affiliation(s)
- Claudia Ringhofer
- University Clinic of Surgery, Medical University Vienna, Vienna, Austria
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41
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Johansson J, Håkansson HO, Mellblom L, Kempas A, Johansson KE, Granath F, Nyrén O. Risk factors for Barrett's oesophagus: a population-based approach. Scand J Gastroenterol 2007; 42:148-56. [PMID: 17327933 DOI: 10.1080/00365520600881037] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Given its often subclinical course, Barrett's oesophagus (BO) hardly lends itself to epidemiologically stringent evaluations. The objective of this study was to investigate risk factors for incident BO diagnosed in a defined population in southeast Sweden while paying particular attention to epidemiological aspects of the study design. MATERIAL AND METHODS Consecutive patients (aged 18-79 years) who were endoscoped with new indications at units exclusively responsible for all gastroscopies in defined catchment area populations were invited to take part in the study. Biopsies were taken above and immediately below the gastro-oesophageal junction, and exposure information was collected through self-administered questionnaires. Endoscopy-room-based cross-sectional data from 604 patients were supplemented with exposure data from 160 population controls. Associations, expressed as odds ratios (ORs), were modelled by means of multivariable logistic regression. RESULTS In the comparison with population controls, reflux symptoms and smoking indicated a 10.7- and 3.3-fold risk, respectively, for BO (95% confidence interval (CI) 3.5-33.4 and 1.1-9.9, respectively). Body mass was unrelated to risk. In the cross-sectional analysis among endoscopy-room patients, reflux symptoms were associated with an OR of 2.0 (95% CI 0.8-5.0). This association was, however, modified by the subjunctional presence of Helicobacter pylori; although the infection was not in itself significantly connected with risk, a combination of reflux symptoms and H. pylori infection was linked to an almost 5-fold risk (95% CI 1.4-16.5) as compared with the absence of both factors. The BO prevalence increased by 5% per year of age (95% CI 1-9%). CONCLUSIONS Reflux is the predominant risk factor for BO, and proximal gastric colonization of H. pylori seems to amplify this risk.
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