Inlet patch: associations with endoscopic findings in the upper gastrointestinal system

Incidence of Acute Upper Gastrointestinal Bleeding and Related Risk Factors among Elderly Patients Undergoing Surgery for Major Limb Fractures: An Analytical Cohort Study

(1) Background: Upper gastrointestinal bleeding (UGIB), a major postoperative complication after surgical fixation of major limb fractures, can be fatal but is often neglected. This study determined the incidence rates of and related risk factors for perioperative UGIB among older patients with major upper limb fractures but without a history of peptic ulcer disease (PUD). (2) Methods: We collected the data of patients aged more than 65 years who underwent surgery for major limb fracture between 1 January 2001 and 31 December 2017, from Taiwan's National Health Insurance Research Database and excluded those with a history of UGIB and PUD before the date of surgery. The primary outcome was the incidence of UGIB requiring panendoscopy during hospitalization. A multiple logistic regression model was used to identify the independent predictors of UGIB, with adjustment for confounding factors. The final model included variables that were either statistically significant in univariate analyses or deemed clinically important. (3) Results: The incidence of UGIB was 2.8% among patients with major limb fractures. Male sex, older age, major lower limb fracture, and a history of chronic renal disease were significant risk factors for the increased incidence of perioperative UGIB. (4) Conclusions: Patients with major limb fractures who underwent surgery exhibited a higher rate of stress ulceration with UGIB, even when they had no history of PUD. Perioperative preventive protocols (e.g., protocols for the administration of proton-pump inhibitors) may be necessary for patients with these major risk factors.

Esophageal Inlet Patch: Association with Barrett's Esophagus

BACKGROUND

Esophageal inlet patch (IP) with heterotopic gastric mucosa is an incidental finding on esophagogastroduodenoscopy (EGD). Although IP is thought to be embryologic in nature, IP has been associated with Barrett's esophagus (BE).

AIMS

The aim of this study was to compare prevalence, symptoms, demographic factors, and esophageal testing in patients with IP and BE.

METHODS

We retrospectively analyzed endoscopic findings of EGDs, high-resolution esophageal manometry and esophageal pH impedance studies from January 2010 to January 2021 at a single academic medical center. Patients were grouped by presence or absence of IP and BE.

RESULTS

Of 27,498 patients evaluated, 1.3% had endoscopic evidence of IP and 4.9% had BE. Of 362 patients with IP, 17.1% had BE; of 1356 patients with BE, 4.6% had IP. Both IP and BE patients presented primarily with heartburn and/or regurgitation. Patients with BE and/or IP were older and had higher BMI than those without (p < 0.001). Mean lower esophageal sphincter pressure was lower and mean acid exposure time (AET) was higher in patients with IP and/or BE than those without (p < 0.05).

CONCLUSIONS

Our study reports an IP prevalence of 1.3%, with 17.1% patients having concomitant BE; and a BE prevalence of 4.9%, with 4.6% also having IP. Patients with IP alone presented with similar symptoms to patients with concomitant BE. Esophageal function testing showed that patients with either IP or BE had decreased LES pressures and increased esophageal AET. During endoscopy, patients found to have one of these findings should be carefully examined for the other.

Heterotopic Gastric Mucosa in the Proximal Esophagus: Prospective Study and Systematic Review on Relationships with Endoscopic Findings and Clinical Data

Cervical inlet patches (CIP) are common endoscopic findings with uncertain pathogenesis and clinical significance. We aimed to perform a systematic review and prospective study of clinical data and endoscopic findings related to CIP. It was a prospective single-center study conducted between 10/01/2017 and 9/01/2018. Forty patients with histopathologically confirmed CIP were compared with 222 individuals in the reference group. The systematic review was executed in accordance with the PRISMA guideline. Alcohol consumption tended to be higher among patients with CIP (3.0 ± 4.6 vs. 1.9 ± 5.0 standard drinks/week CIP patients and reference group, respectively; p < 0.001). Dysphagia was more frequent among patients with CIP (25% vs. 1.4%, CIP patients and reference group, respectively; p < 0.001), and sore throat and hoarseness were less frequent in patients with CIP (17.5% vs. 26.6% CIP patients and reference group, respectively; p < 0.01). In the multivariate regression analysis, the only risk factor of CIP occurrence was dysphagia (OR 21.9, 95%CI 4.9-98.6; p < 0.001). Sore throat and hoarseness were a reverse-risk factor of CIP diagnosis (OR 0.3, 95%CI 0.1-0.93; p = 0.04). Clinical data and coexisting endoscopic findings were not related to CIP. In the presented study, dysphagia was related to CIP occurrence, and sore throat and hoarseness tended to be less frequent among patients with CIP.

Prevalence and Clinical and Endoscopic Characteristics of Cervical Inlet Patch (Heterotopic Gastric Mucosa): A Systematic Review and Meta-Analysis

BACKGROUND

Cervical inlet patch (CIP), also called gastric inlet patch, is a heterotopic columnar mucosal island located in the cervical esophagus, which has been under-recognized by clinicians.

AIM

We conducted a systemic review and meta-analysis to explore the prevalence and clinical and endoscopic characteristics of CIP.

MATERIALS AND METHODS

Studies were searched through the PubMed, EMBASE, and Cochrane Library databases. The prevalence of CIP with 95% confidence interval (CI) was pooled by using a random-effect model. The association of CIP with demographics, clinical presentations, and endoscopic features was evaluated by odds ratios (ORs).

RESULTS

Fifty-three studies including 932,777 patients were eligible. The pooled prevalence of CIP was 3.32% (95% CI=2.86%-3.82%). According to the endoscopic mode, the pooled prevalence of CIP was higher in studies using narrow-band imaging than in those using white light and esophageal capsule endoscopy (9.34% vs. 2.88% and 0.65%). The pooled prevalence of CIP was higher in studies where the endoscopists paid specific attention to the detection of this lesion (5.30% vs. 0.75%). CIP was significantly associated with male (OR=1.24, 95% CI=1.09-1.42, P=0.001), gastroesophageal reflux disease (OR=1.32, 95% CI=1.04-1.68, P=0.03), reflux symptoms (OR=1.44, 95% CI=1.14-1.83, P=0.002), dysphagia (OR=1.88, 95% CI=1.28-2.77, P=0.001), throat discomfort (OR=4.58, 95% CI=1.00-21.02, P=0.05), globus (OR=2.95, 95% CI=1.52-5.73, P=0.001), hoarseness (OR=4.32, 95% CI=1.91-9.78, P=0.0004), cough (OR=3.48, 95% CI=1.13-10.72, P=0.03), Barrett's esophagus (OR=2.01, 95% CI=1.37-2.94, P=0.0003), and esophagitis (OR=1.62, 95% CI=1.27-2.07, P=0.0001).

CONCLUSION

CIP appears to be common by using narrow-band imaging, especially if the endoscopists would like to pay attention to the detection of this lesion. CIP is clearly associated with acid-related symptoms and Barrett's esophagus.

Influence of narrow-band imaging (NBI) and enhanced operator's attention during esophagus inspection on cervical inlet patches detection

PURPOSE

Heterotopic gastric mucosa in the upper esophagus (cervical inlet patches - CIP) may be easily missed during esophagogastroduodenoscopy (EGD) due to low awareness of this usually, but not invariably, benign lesion. Narrow-band imaging (NBI) emphasizes contrast between normal esophageal mucosa and CIP. The purpose of this study was to investigate how NBI use and enhanced attention of operator during inspection of upper esophagus impacts cervical inlet patch detection rate (CIPDR).

MATERIALS AND METHODS

This is a prospective, randomized study in which we enrolled 1000 patients, qualified for diagnostic EGD. The trial was divided into two parts; the first, when 6 operators performed EGD with standard attention (SA), and the second, when the same operators were asked to step up with attention at CIP (enhanced attention - EA). In both parts of the study, patients were randomized to NBI and white light endoscopy (WLE) in 1:1 ratio. The study is registered in ClinicalTrials.gov (No. NCT03015571).

RESULTS

Differences in CIPDR between WLE and NBI in SA and EA were not statistically different (5.6% vs 7.6%; p ​= ​0.3, and 7.6% vs 11.6%; p ​= ​0.1, respectively). In multivariate regression analysis, the only factors improving CIPDR were NBI with EA (NBI_EA, OR 3.31; 95%CI 1.57-6.98; p ​= ​0.003) and sedation (OR 1.97; 95%CI 1.27-3.05; p ​= ​0.002).

CONCLUSIONS

The use of NBI combined with EA significantly improves CIPDR.

Gastric inlet patches: symptomatic or silent?

PURPOSE OF REVIEW

The purpose of this review is to assess recent literature on the clinical relevance of the gastric inlet patch with particular focus on endoscopic diagnosis and treatment, the relationship of the inlet patch to laryngopharyngeal reflux disease and the association of proximal esophageal adenocarcinoma with inlet patch.

RECENT FINDINGS

Recent studies suggest endoscopic diagnosis of inlet patch increases with endoscopist awareness (up to 10-fold) and when using enhanced imaging techniques such as narrow band imaging (up to three-fold). The literature remains mixed on the association of inlet patch with laryngopharyngeal symptoms or globus sensation. Studies of endoscopic ablation, using argon plasma coagulation or radiofrequency ablation have shown improved laryngopharyngeal reflux symptom scores posttreatment. Proximal esophageal adenocarcinomas are rare but often associated with inlet patch when they occur. Case studies have described endoscopic resection of malignant lesions related to inlet patch, using endoscopic mucosal resection or submucosal dissection.

SUMMARY

Prospective, multicenter studies of symptom association with inlet patch using validated symptom questionnaires and blinded sham-controlled treatments are needed to further clarify the role of such treatments, which to date are limited to a small numbers of centers with a special interest.

Cervical inlet patch: new insights into diagnosis and endoscopic therapy

The cervical inlet patch is an island of heterotopic gastric mucosa, most commonly found in the proximal oesophagus. Its importance as a cause of throat symptoms has been recognised, particularly chronic globus sensation. This has led to a change in the Rome IV criteria for globus management, with emphasis on ruling out the condition. Proton pump inhibitors are often ineffective in resolving symptoms. Endoscopic studies on the use of ablative techniques, most recently radiofrequency ablation (RFA), have shown promise in reversing the CIP to mormal squamous mucosa, with subsequent symtpomatic resolution. The aim of this review is to update on the investigation and management of the CIP.

A 14-Year Study of 398 Esophageal Adenocarcinomas Diagnosed Among 156,256 EGDs Performed at Two Large Hospitals: An Inlet Patch Is Proposed as a Significant Risk Factor for Proximal Esophageal Adenocarcinoma

BACKGROUND

An association between inlet patches and proximal esophageal adenocarcinomas is currently suspected because of numerous case reports of simultaneous occurrence of both diseases.

AIMS

To analyze whether inlet patches are significantly associated with proximal esophageal adenocarcinomas in a large population.

METHODS

Computerized search of pathology and EGD reports revealed 398 cases of esophageal adenocarcinomas among 156,236 EGDs (performed on 106,510 patients) diagnosed by histopathology performed at Royal Oak/Troy, William Beaumont Hospitals, 2003-2016. Adenocarcinomas localized as distal, middle, or proximal; and characterized as associated versus unassociated with inlet patches. Medical records were reviewed. Endoscopic photographs, radiologic images, and pathologic slides were re-reviewed. Two researchers independently performed systematic computerized literature searches; cases of simultaneous diseases identified by consensus.

RESULTS

Adenocarcinoma locations included: distal-381, middle-14, and proximal esophagus-3. Five patients had inlet patches with esophageal adenocarcinomas located at: distal-2, middle-0, and proximal esophagus-3 (relative frequency of inlet patches with cancers of distal/middle esophagus = 2/395 [.5%] vs. proximal esophagus = 3/3 [100%], p < .000001, 95% OR CI > 50.1, Fisher's exact test). Cases of proximal esophageal adenocarcinomas within inlet patches included: (1) Seventy-eight-year-old man presented with dysphagia. Neck CT showed proximal esophageal mass. EGD revealed semi-circumferential, multinodular, 3.0 × 1.5 cm mass within inlet patch. Histopathology of biopsies revealed moderately-to-poorly differentiated adenocarcinoma. Patient received chemoradiotherapy and expired 2 years later. (2) Seventy-nine-year-old man presented with anorexia and weight loss. EGD demonstrated proximal esophageal mass within inlet patch. Histopathology of biopsies revealed poorly differentiated, signet ring cell adenocarcinoma. Chest CT revealed 3.4 × 2.1-cm-proximal esophageal mass. Patient expired 4 months later. (3) Sixty-year-old man presented with dysphagia. EGD revealed 4-cm-long, semi-circumferential, proximal esophageal mass within inlet patch. Histopathology of biopsies revealed poorly differentiated adenocarcinoma. Patient underwent emergency esophagectomy for esophageal perforation 2 weeks after initiating chemoradiotherapy, and died shortly thereafter. Literature review revealed 39 cases of simultaneous disease.

STUDY LIMITATIONS

Potential underreporting by endoscopists of inlet patches at EGD.

CONCLUSIONS

Study supplements 39 previously reported cases of simultaneous disease, by adding three new cases, and by novel report of statistically significant association between these two entities, which has important implications in the pathophysiology of proximal esophageal adenocarcinoma.

The prevalence of gastric heterotopia of the proximal esophagus is underestimated, but preneoplasia is rare - correlation with Barrett's esophagus

BACKGROUND

The previously reported prevalence of gastric heterotopia in the cervical esophagus, also termed inlet patch (IP), varies substantially, ranging from 0.18 to 14%. Regarding cases with adenocarcinoma within IP, some experts recommend to routinely obtain biopsies from IP for histopathology. Another concern is the reported relation to Barrett's esophagus. The objectives of the study were to prospectively determine the prevalence of IP and of preneoplasia within IP, and to investigate the association between IP and Barrett's esophagus.

METHODS

372 consecutive patients undergoing esophagogastroduodenoscopy were carefully searched for the presence of IP. Biopsies for histopathology were targeted to the IP, columnar metaplasia of the lower esophagus, gastric corpus and antrum. Different definitions of Barrett's esophagus were tested for an association with IP.

RESULTS

At least one IP was endoscopically identified in 53 patients (14.5%). Histopathology, performed in 46 patients, confirmed columnar epithelium in 87% of cases, which essentially presented corpus and/or cardia-type mucosa. Intestinal metaplasia was detected in two cases, but no neoplasia. A previously reported association of IP with Barrett's esophagus was weak, statistically significant only when short segments of cardia-type mucosa of the lower esophagus were included in the definition of Barrett's esophagus.

CONCLUSIONS

The prevalence of IP seems to be underestimated, but preneoplasia within IP is rare, which does not support the recommendation to regularly obtain biopsies for histopathology. Biopsies should be targeted to any irregularities within the heterotopic mucosa. The correlation of IP with Barrett's esophagus hints to a partly common pathogenesis.

Benign esophageal lesions: Endoscopic and pathologic features

Benign esophageal lesions have a wide spectrum of clinical and pathologic features. Understanding the endoscopic and pathologic features of esophageal lesions is essential for their detection, differential diagnosis, and management. The purpose of this review is to provide updated features that may help physicians to appropriately manage these esophageal lesions. The endoscopic features of 2997 patients are reviewed. In epithelial lesions, the frequency of occurrence was in the following order: glycogenic acanthosis, heterotopic gastric mucosa, squamous papilloma, hyperplastic polyp, ectopic sebaceous gland and xanthoma. In subepithelial lesions, the order was as follows: hemangioma, leiomyoma, dysphagia aortica and granular cell tumor. Most benign esophageal lesions can be diagnosed according to their endoscopic appearance and findings on routine biopsy, and submucosal lesions, by endoscopic resection. Management is generally based upon the confidence of diagnosis and whether the lesion causes symptoms. We suggest endoscopic resection of all granular cell tumors and squamous papillomas because, while rare, these lesions have malignant potential. Dysphagia aortica should be considered in the differential diagnosis of dysphagia in the elderly.

Heterotopic gastric mucosa of upper oesophagus: evaluation of 12 cases during gastroscopic examination

INTRODUCTION

Oesophageal heterotopic gastric mucosa mostly presents in the upper part of the oesophagus. It is commonly under-diagnosed because of its localisation.

AIM

To expose the association between heterotopic gastric mucosa and endoscopic features of the upper gastrointestinal tract.

MATERIAL AND METHODS

A total of 1860 upper endoscopic examinations performed between January 2012 and July 2013 were analysed retrospectively. Endoscopic features and histological examinations of 12 heterotopic gastric mucosa (HGM) of the upper oesophagus were documented and evaluated retrospectively.

RESULTS

There were 7 (58%) male and 5 (42%) female patients aged between 22 and 80 years with a mean age of 43.2 years. Heterotopic gastric mucosa was present in 12 (0.6%) of all patients. We were able to perform biopsy for histopathological observation on 8 (66%) of the 12 patients in which HGM was seen during endoscopy. Five (42%) patients with heterotopic gastric mucosa had oesophagitis. Los Angeles Grade A oesophagitis was found in all patients, and histologically proven Barrett's oesophagus was detected in only one patient.

CONCLUSIONS

When a patient has ongoing dyspeptic complaints and reflux symptoms despite the treatment, one should be careful about possible HGM during upper gastrointestinal endoscopy. The point to be taken into consideration for patients who have metaplasia or dysplasia within HGM may need to be considered for surveillance.

Narrow band imaging facilitates detection of inlet patches in the cervical oesophagus

BACKGROUND

Proximal esophageal heterotopic gastric mucosa or so-called inlet patch in the cervical oesophagus is easily missed on endoscopic examination because of its localisation, usually just below the upper oesophageal sphincter. We evaluated the clinical use of narrow band imaging for detection of inlet patches.

METHODS

In this prospective, controlled observational study, 1407 subsequent patients underwent oesophagogastroduodenoscopy with or without narrow band imaging on withdrawal of the endoscope in the cervical oesophagus.

RESULTS

One endoscopist who was not aware of the prospective observation documented 6 (1.17%) cases of inlet patches in 515 oesophagogastroduodenoscopies compared to 4 cases out of 382 (1.05%) performed by the endoscopist who paid special attention to the presence of inlet patches but did not routinely apply narrow band imaging (OR 0.89, CI 95% 0.25-3.20, p=0.85). In comparison, 17 cases of inlet patches out of 510 (3.33%) were detected by the endoscopist who routinely applied narrow band imaging. The detection rate of proximal oesophageal heterotopic gastric mucosa using narrow band imaging was significantly higher compared to white light endoscopy only (OR 3.06, CI 95% 1.39-6.73, p=0.005).

CONCLUSIONS

Withdrawal of the endoscope from the cervical oesophagus using narrow band imaging increased the detection of inlet patches about three-fold compared to standard white light endoscopy.

Endoscopic Optical Coherence Tomography for Clinical Gastroenterology

Optical coherence tomography (OCT) is a real-time optical imaging technique that is similar in principle to ultrasonography, but employs light instead of sound waves and allows depth-resolved images with near-microscopic resolution. Endoscopic OCT allows the evaluation of broad-field and subsurface areas and can be used ancillary to standard endoscopy, narrow band imaging, chromoendoscopy, magnification endoscopy, and confocal endomicroscopy. This review article will provide an overview of the clinical utility of endoscopic OCT in the gastrointestinal tract and of recent achievements using state-of-the-art endoscopic 3D-OCT imaging systems.

Endoscopic diagnosis of cervical esophageal heterotopic gastric mucosa with conventional and narrow-band images

AIM: To compare the diagnostic yield of heterotopic gastric mucosa (HGM) in the cervical esophagus with conventional imaging (CI) and narrow-band imaging (NBI).

METHODS: A prospective study with a total of 760 patients receiving a CI examination (mean age 51.6 years; 47.8% male) and 760 patients undergoing NBI examination (mean age 51.2 years; 45.9% male). The size of HGM was classified as small (1-5 mm), medium (6-10 mm), or large (> 1 cm). A standardized questionnaire was used to obtain demographic characteristics, social habits, and symptoms likely to be related to cervical esophageal HGM, including throat symptoms (globus sensation, hoarseness, sore throat, and cough) and upper esophageal symptoms (dysphagia and odynophagia) at least 3 mo in duration. The clinicopathological classification of cervical esophageal HGM was performed using the proposal by von Rahden et al.

RESULTS: Cervical esophageal HGM was found in 36 of 760 (4.7%) and 63 of 760 (8.3%) patients in the CI and NBI groups, respectively (P = 0.007). The NBI mode discovered significantly more small-sized HGM than CI (55% vs 17%; P < 0.0001). For the 99 patients with cervical esophageal HGM, biopsies were performed in 56 patients; 37 (66%) had fundic-type gastric mucosa, and 19 had antral-type mucosa. For the clinicopathological classification, 77 patients (78%) were classified as HGM I (asymptomatic carriers); 21 as HGM II (symptomatic without morphologic changes); and one as HGM III (symptomatic with morphologic change). No intraepithelial neoplasia or adenocarcinoma was found.

CONCLUSION: NBI endoscopy detects more cervical esophageal HGM than CI does. Fundic-type gastric mucosa constitutes the most common histology. One-fifth of patients have throat or dysphagic symptoms.

Clinical significance of heterotopic gastric mucosal patch of the proximal esophagus

Heterotopic gastric mucosa of the proximal esophagus (HGMPE), also referred to as “inlet patch” or “cervical inlet patch”, is a salmon colored patch that is usually located just distal to the upper esophageal sphincter. HGMPE is uncommon with endoscopic studies reporting a prevalence ranging from less than one percent to 18%. Most HGMPE are asymptomatic and are detected incidentally during endoscopy for evaluations of other gastrointestinal complaints. Most consider HGMPE as clinically irrelevant entity. The clinical significance of HGMPE is mainly acid related or neoplastic transformation. The reported prevalence of laryngopharyngeal reflux symptoms varies from less than 20% to as high as 73.1%. However, most of these symptoms are mild. Clinically significant acid related complications such as bleeding, ulcerations, structure and fistulization have been reported. Although rare, dysplastic changes and malignancies in association with HGMPE have also been reported. Associations with Barrett’s esophagus have also been reported but the findings so far have been conflicting. There are still many areas that are unknown or not well understood and these include the natural history of HGMPE, risk factors for complications, role of Helicobacter pylori infection and factors associated with malignant transformations. Follow-up may need to be considered for patients with complications of HGMPE and surveillance if biopsies show intestinal metaplasia or dysplastic changes. Despite the overall low incidence of clinically relevant manifestations reported in the literature, HGMPE is a clinically significant entity but further researches are required to better understand its clinical significance.

Cervical inlet patch-optical coherence tomography imaging and clinical significance

AIM: To demonstrate the feasibility of optical coherence tomography (OCT) imaging in differentiating cervical inlet patch (CIP) from normal esophagus, Barrett’s esophagus (BE), normal stomach and duodenum.

METHODS: This study was conducted at the Veterans Affairs Boston Healthcare System (VABHS). Patients undergoing standard esophagogastroduodenoscopy at VABHS, including one patient with CIP, one representative patient with BE and three representative normal subjects were included. White light video endoscopy was performed and endoscopic 3D-OCT images were obtained in each patient using a prototype OCT system. The OCT imaging probe passes through the working channel of the endoscope to enable simultaneous video endoscopy and 3D-OCT examination of the human gastrointestinal (GI) tract. Standard hematoxylin and eosin (H and E) histology was performed on biopsy or endoscopic mucosal resection specimens in order to compare and validate the 3D-OCT data.

RESULTS: CIP was observed from a 68-year old male with gastroesophageal reflux disease. The CIP region appeared as a pink circular lesion in the upper esophagus under white light endoscopy. OCT imaging over the CIP region showed columnar epithelium structure, which clearly contrasted the squamous epithelium structure from adjacent normal esophagus. 3D-OCT images obtained from other representative patients demonstrated distinctive patterns of the normal esophagus, BE, normal stomach, and normal duodenum bulb. Microstructures, such as squamous epithelium, lamina propria, muscularis mucosa, muscularis propria, esophageal glands, Barrett’s glands, gastric mucosa, gastric glands, and intestinal mucosal villi were clearly observed with OCT and matched with H and E histology. These results demonstrated the feasibility of using OCT to evaluate GI tissue morphology in situ and in real-time.

CONCLUSION: We demonstrate in situ evaluation of CIP microstructures using 3D-OCT, which may be a useful tool for future diagnosis and follow-up of patients with CIP.

Symptomatic gastric inlet patches in children treated with argon plasma coagulation: a case series

The pathologic potential of gastric inlet patches is now being recognized. A recent adult study has shown the effectiveness of argon plasma coagulation in ablating the patch and the associated symptoms. There are no reports of ablation in children. We report a case series of successful argon plasma coagulation of gastric inlet patches and their symptoms in 5 children.

Gastric heterotopia in the proximal oesophagus ("inlet patch"): Association with adenocarcinomas arising in Barrett mucosa

BACKGROUND

The prevalence of inlet patches and their association with other conditions of the gastrointestinal tract have been studied prospectively in tertiary care facilities; little is known about practice patterns in private outpatient clinics and endoscopy centres.

AIMS

To assess prevalence, demographic determinants, and associated clinicopathologic features of inlet patches in patients who had oesophagogastroduodenoscopy in outpatient settings throughout the United States.

METHODS

Retrospective analysis of the clinicopathologic records of 487,229 unique patients who had oesophagogastroduodenoscopy with biopsies between January 2008 and December 2010.

RESULTS

There were 870 patients with inlet patches with a prevalence of 0.18%. Significant associations included male gender (OR 1.68), dysphagia (OR 1.34), upper respiratory complaints (OR 2.81), globus (OR 5.39) Barrett oesophagus (OR 1.55), and adenocarcinomas arising in Barrett mucosa (OR 5.64).

CONCLUSIONS

The prevalence of inlet patches in a tertiary care setting (0.18%) was considerably lower than reported in prospective studies (3.7% on average). Inlet patches were significantly associated with male gender, dysphagia, upper respiratory complaints, globus, Barrett mucosa, and adenocarcinomas arising in Barrett oesophagus. Further studies will be needed to determine if patients with inlet patches and Barrett mucosa benefit from increased surveillance.

High oesophageal web formation in association with heterotopic gastric mucosa (the gastric inlet patch): a small case series

BACKGROUND

Upper oesophageal webs or rings have rarely been reported in association with heterotopic gastric mucosa (HGM).

OBJECTIVE

To describe the finding of oesophageal webs in association with HGM.

DESIGN

Small case series.

SETTING

Patients presenting with dysphagia to an open access hospital dysphagia clinic.

PATIENTS

Six cases were found.

INTERVENTIONS

Symptomatic improvement is demonstrated with oesophageal dilatation in symptomatic patients.

MAIN OUTCOME MEASUREMENTS

Symptomatic improvement.

RESULTS

The six cases which are described here demonstrate that a web or ring exactly matches the distribution of the heterotopic mucosa, can occur at both proximal and distal squamo-columnar junctions and the inlet patches may be multiple with multiple rings. A radiological double web sign is described.

LIMITATIONS

A rare condition with a small number of patients.

CONCLUSIONS

Effective treatment can be by oesophageal dilatation and acid suppression. The cause of web formation is thought to be due to heterotopic acid production and is analogous to the Schatzki ring.

Heterotopic gastric mucosal patch in patients with reflux laryngitis: an entity of clinical interest?

Heterotopic gastric mucosal patch (HGMP) in the upper esophagus has been suggested to play a role in the pathogenesis of laryngopharyngeal reflux. The aim of this study was to evaluate the prevalence and possible clinical significance of HGMPs in patients who underwent laparoscopic Nissen fundoplication for gastroesophageal reflux disease-induced reflux laryngitis.Forty consecutive patients with pH-proven reflux laryngitis referred to surgery by a specialist in otorhinolaryngology underwent laparoscopic Nissen fundoplication between 1998 and 2002. Twenty-seven (67.5%) of these patients underwent a postoperative upper gastrointestinal endoscopy paying special attention for detecting possible HGMPs in the proximal esophagus. When HGMP was found, biopsies were taken for histologic confirmation. A small histologically confirmed HGMP was detected in 1 out of 27 patients (3.7%). The prevalence of HGMPs in the upper esophagus in this specific patient group operated on for gastroesophageal reflux disease-induced reflux laryngitis equals the reported general prevalence rates of HGMPs detected in patients referred for upper gastrointestinal endoscopy as a part of gastrointestinal tract evaluation. The role of at least small HGMPs in the proximal esophagus in the pathogenesis of laryngopharyngeal reflux is clinically insignificant.

Non-erosive reflux disease rather than cervical inlet patch involves globus

BACKGROUND

Gastroesophageal reflux is the most favored etiology for globus; however, recent studies suggest that a cervical inlet patch (heterotopic gastric mucosa in the cervical esophagus) involves globus. This study aimed to reveal whether these two conditions were associated with globus.

METHODS

A prospective cross-sectional survey was conducted for 2116 consecutive patients who underwent esophagogastroduodenoscopy in our hospital. Patients were interviewed about globus sensations and reflux symptoms prior to endoscopy. Non-erosive reflux disease was considered with reflux symptoms without reflux esophagitis. Inlet patch was detected using narrow-band imaging.

RESULTS

Sixty-three patients were excluded, and of the remaining 2053 patients (1117 male, 61 years old on average), 120 (5.8%) and 284 (13.8%) had globus and inlet patch, respectively. Multivariate analysis (n = 1584) following the exclusion of proton pump inhibitor users revealed that female gender, younger age (<60), inlet patch, and reflux symptoms were independent risk factors for the development of globus; however, reflux esophagitis was an independent factor for reducing the development of globus. In a reanalysis of non-erosive reflux disease instead of reflux symptoms, inlet patch and non-erosive reflux disease were independent risk factors for the development of globus (odds ratio, 2.9 and 12.1, respectively).

CONCLUSIONS

Non-erosive reflux disease was more closely associated with globus than an inlet patch. Our controversial results indicating a strong association of globus with non-erosive reflux disease and an inverse association of globus with reflux esophagitis may suggest that mechanisms other than gastroesophageal reflux as the etiology, such as an esophageal visceral hypersensitivity, involve globus.

Heterotopic gastric mucosal patch of the esophagus is associated with higher prevalence of laryngopharyngeal reflux symptoms

Laryngopharyngeal reflux (LPR) is common in clinical practice. Heterotopic gastric mucosal patch of the proximal esophagus (HGMP) is reported to cause LPR symptoms. This study assessed the prevalence of LPR symptoms and correlation with the size of HGMP. Four hundred and sixty-two patients undergoing endoscopy were carefully questioned regarding LPR symptoms experienced in the previous 12 weeks. The size of the HGMP was assessed and documented during endoscopy. Clinicopathological classifications were assigned (types I-V) accordingly. HGMP [median one patch (range 1-3), median size 15 mm [3-35] was detected in 26 (19 HGM type I and 7 HGM type II] patients giving a prevalence of 5.6%. Among the indications, there were significantly more LPR symptoms as referral indications among patients with HGMP. There were no significant differences in the endoscopic findings. On specific enquiries, significantly more HGMP patients had experienced any LPR symptoms (73.1 vs. 25.9%, p < 0.001) specifically chronic cough (p = 0.002), throat discomfort/hoarseness (p < 0.001), globus sensation (p = 0.004), regurgitation (p < 0.001). HGMP patients also had more heartburn (p = 0.001). Larger HGMP (≥ 15 mm) was only associated with more chronic cough (p = 0.022). In conclusion, patients with HGMP have significantly more LPR symptoms. However, most were mild and detected through specific enquiries. Interestingly, the size of HGMP did not significantly affect the prevalence of LPR symptoms.