Cytokeratins 7 and 20 and mucin core protein expression in esophageal cervical inlet patch

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.

Not Every Dyspepsia Is Related to Helicobacter pylori-A Case of Esophageal Inlet Patch in a Female Teenager

Helicobacter pylori infection is one of the main causes of dyspepsia, but it is not the only cause. Esophageal inlet patches are areas of heterotopic gastric mucosa within the esophagus and are commonly located in the cervical part of the esophagus. We report the case of a 16-year-old female, previously known to display symptoms of anxiety, who was admitted to our clinic for dyspeptic symptoms lasting for approximately 1 month in spite of the treatment with proton pump inhibitors. The clinical exam revealed only abdominal tenderness in the epigastric area, while routine laboratory tests showed no abnormalities. The upper digestive endoscopy revealed a well-circumscribed salmon-pink-colored oval lesion of approximately 10 mm in the cervical esophagus, along with hyperemia of the gastric mucosa and biliary reflux. The histopathological exam established the diagnosis of esophageal inlet patch with heterotopic antral-type gastric mucosa and also revealed regenerative changes within the gastric mucosa. We continued to treat the patient with proton pump inhibitors, as well as ursodeoxycholic acid, with favorable evolution. Although rare or underdiagnosed, esophageal inlet patches should never be underestimated and all gastroenterologists should be aware of their presence when performing an upper digestive examination in a patient with dyspeptic symptoms.

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.

Issues and controversies in esophageal inlet patch

The proximal esophagus is rarely examined, and its inspection is often inadequate. Optical chromoendoscopy techniques such as narrow band imaging improve the detection rate of inlet patches in the proximal esophagus, a region in which their prevalence is likely underestimated. Various studies have reported correlations between these esophageal marks with different issues such as Barrett's esophagus, but these findings remain controversial. Conflicting reports complicate the process of interpreting the clinical features of esophageal inlet patches and underestimate their importance. Unfortunately, the limited clinical data and statistical analyses make reaching any conclusions difficult. It is hypothesized that inlet patches are correlated with various esophageal and extraesophageal symptoms, diagnoses and the personalized therapeutic management of patients with inlet patches as well as the differential diagnosis for premalignant lesions or early cancers. Due to its potential underdiagnosis, there are no consensus guidelines for the management and follow up of inlet patches. This review focuses on questions that were raised from published literature on esophageal inlet patches in adults.

[Heterotopic tissue in the gastrointestinal tract]

Heterotopia of the gastrointestinal tract is a common finding. This is due to the complex embryogenesis and the relative ease to detect heterotopic tissue during endoscopy. The reason for biopsy is mostly to rule out neoplasms or to define specific causes of inflammation. Heterotopic tissue can occur in any location of the gastrointestinal tract. The most frequent are gastric heterotopia, pancreatic heterotopia, and heterotopia of Brunner's gland. On rare occasions, heterotopic tissue of salivary gland type as well as heterotopias of apocrine glands, thyroid, and prostatic tissue have been described. The most frequently involved organs are the small intestine, in particular the duodenum, the esophagus, and the stomach. Heterotopia of the large bowel occurs exclusively in the rectum. Most heterotopias do not cause symptoms and are easily diagnosed by biopsy and histology. However, depending on location, size, and the kind of underlying heterotopic tissue, they may cause significant complications, such as inflammation, ulceration and perforation, obstruction, intussusception, and severe life-threatening bleeding. Another rare but significant complication is neoplasia. Gastric heterotopias may give rise to pyloric gland adenomas within the bowel or rarely adenocarcinomas of the esophagus. Pancreatic heterotopia can be complicated by ductal type pancreatic adenocarcinomas, by acinus cell carcinomas, by intraductal papillary mucinous neoplasias, and also by endocrine tumors. The present paper summarizes our current knowledge about heterotopias in a topographic clinico-pathological manner.

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.

Review of Current Applications of Immunohistochemistry in Pediatric Nonneoplastic Gastrointestinal, Hepatobiliary, and Pancreatic Lesions

Immunohistochemical (IHC) stains are widely used by pathologists for a variety of considerations in the diagnostic workup of pediatric nonneoplastic lesions in gastrointestinal (GI), hepatic, biliary, and pancreatic lesions. The pathologic changes cover a wide range and types of presentations, including inflammatory (bacterial and viral), metaplastic, posttransplant lymphoproliferative, autoimmune, metabolic, degenerative, developmental, and genetic conditions, among others. The everyday practical value of IHC stains covers primary identification, confirmation, differential, and/or exclusionary roles in the hands and eyes and minds of the practitioners. This article is intended to review and discuss the currently available IHC stains for a variety of pediatric GI, hepatobiliary, and pancreatic lesions as encountered in the day-to-day practice of pathologists and clinicians. It reflects the most recent methods and types of IHC stains with the stated aim of helping to provide a quick reference for diagnostic considerations and thereby facilitate the workup of a broad range of GI and related conditions in a pediatric population. The tables provide a handy reference on a wide range of IHC stains for commonly encountered lesions covering a variety of pediatric GI, hepatobiliary, and pancreatic conditions that are amenable to light microscopic diagnostic interpretation.

Adenocarcinoma arising from heterotopic gastric mucosa in the cervical esophagus and upper thoracic esophagus: two case reports and literature review

Primary adenocarcinoma arising from heterotopic gastric mucosa (HGM) is rare and the clinicopathological characteristics are not well known. We present two cases of esophageal adenocarcinoma arising from HGM with a review of a case series. Case 1 was a 78-year-old woman who underwent a periodic medical examination without complaining of any symptoms. Preoperative evaluation suggested esophageal adenocarcinoma arising from the HGM. The patient was treated with endoscopic submucosal dissection. Definitive pathological diagnosis confirmed adenocarcinoma arising from the HGM. Case 2 was a 70-year-old man who underwent a medical examination after complaining of dysphagia. Preoperative diagnosis suggested esophageal adenocarcinoma; however, its origin was unclear. The patient was treated with surgical resection. Definitive pathological diagnosis revealed adenocarcinoma arising from the HGM. In this article, the authors report the clinicopathological features of esophageal adenocarcinoma arising from HGM that were collected from a literature review and our cases.

Heterotopic Gastric Mucosa in the Distal Part of Esophagus in a Teenager: Case Report

Heterotopic gastric mucosa (HGM) of the esophagus is a congenital anomaly consisting of ectopic gastric mucosa. It may be connected with disorders of the upper gastrointestinal tract, exacerbated by Helicobacter pylori. The diagnosis of HGM is confirmed via endoscopy with biopsy. Histopathology provides the definitive diagnosis by demonstrating gastric mucosa adjacent to normal esophageal mucosa. HGM located in the distal esophagus needs differentiation from Barrett's esophagus. Barrett's esophagus is a well-known premalignant injury for adenocarcinoma of the esophagus. Malignant progression of HGM occurs in a stepwise pattern, following the metaplasia-dysplasia-adenocarcinoma sequence.We present a rare case of a teenage girl with HGM located in the distal esophagus, associated with chronic gastritis and biliary duodenogastric reflux. Endoscopy combined with biopsies is a mandatory method in clinical evaluation of metaplastic and nonmetaplastic changes within HGM of the esophagus.

Heterotopic gastric mucosa of the proximal oesophagus (inlet patch): endoscopic prevalence, histological and clinical characteristics in paediatric patients

BACKGROUND

Heterotopic gastric mucosa is found in the proximal oesophagus, just below the upper oesophageal sphincter, and is encountered when the oesophagus is examined carefully during endoscopy.

AIMS

In this study on paediatric patients, we aimed to determine the endoscopic prevalence of heterotopic gastric mucosa of the proximal oesophagus (HGMPO), to identify its macroscopic and histological characteristics and to evaluate its clinical features.

PATIENTS AND METHODS

A total of 1399 patients were examined. Ages, sex, clinical and endoscopic findings of all patients were recorded. Patients with HGMPO were classified in accordance with a clinicopathological classification and information on the treatment and evolution was also recorded.

RESULTS

Of the 1399 patients, 20 (11 male) were found to have HGMPO. The prevalence of HGMPO was determined to be 1.4%. In five patients, the upper oesophageal and laryngopharyngeal symptoms were remarkable. The clinicopathological classification showed that 15 patients were HGMPO type 1 (asymptomatic) and five were type 2 (symptomatic without morphologic changes). There was no significant association of any other endoscopic finding with the presence of an HGMPO. Proton pump inhibitors treatment was initiated in 16 patients, including those with HGMPO type 2. In one type 2 patient who showed no improvement during medical treatment, endoscopic treatment was indicated (argon plasma ablation). In patients with symptoms attributable to the presence of the inlet patch, the proposed treatment resolved clinical symptoms.

CONCLUSION

The presence of HGMPO is not an infrequent finding in thorough endoscopies. Although HGMPO does not usually have a symptomatic progression, it can sometimes lead to supraoesophageal symptoms; thus, treatment should be considered.

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.

Detailed esophageal function and morphological analysis shows high prevalence of gastroesophageal reflux disease and Barrett's esophagus in patients with cervical inlet patch

Although the pathogenesis of cervical inlet patch (CIP) is not fully understood, most authors consider it as a congenital abnormality, whereas others surmise it to be related to gastroesophageal reflux disease (GERD). We aimed to evaluate esophageal function and the prevalence of GERD and Barrett's esophagus in patients with CIP. GERD is defined by the presence of erosive esophagitis or an abnormal pH monitoring. Seventy-one consecutive patients with endoscopic and histological evidence of CIP were prospectively evaluated. Esophageal symptom analysis, 24-hour simultaneous biliary reflux and double-channel pH-monitoring, and esophageal manometry were carried out in 65/71 (92%) patients and in 25 matched controls. Six patients were not suitable for testing and were, therefore, excluded. The histological evaluation of the heterotopic islands showed cardia and/or oxyntic mucosa in 64/65 (98%) patients and specialized intestinal metaplasia (SIM) in one patient (2%). The cardia and/or oxyntic mucosa was accompanied by focally appearing pancreatic acinar metaplasia and pancreatic ductal metaplasia in 7/64 (11%) and in 1/64 (2%), superficial mucous glands in 6/64 (9%), and SIM in 2/64 (3%) cases. In total, SIM was present in three patients (5%), and one of them had low-grade dysplasia. At the gastroesophageal junction, 28 (43%) patients had columnar metaplasia, including nine (14%) patients with SIM. Erosive esophagitis was present in 37 (57%) cases. Thirty-two patients (49%) had abnormal acid reflux in the distal and 25 (38%) in the proximal esophagus. Abnormal biliary reflux was present in 25 (38%) cases. On the basis of endoscopic and pH studies, GERD was established in 44/65 (68%) patients. Typical reflux symptoms were common (33/65, 51%). The combined 24-hour biliary and double-channel pH-monitoring detected significantly more significant acidic reflux at both measurement points and significantly longer bile exposure time in the distal esophagus in patients with CIP. Acid secretion in the CIP was detected in three (5%) cases. Esophageal manometry revealed decreased LES pressure and prolonged relaxation with decreased peristaltic wave amplitude, and an increased number of simultaneous contractions in the esophageal body. The detailed evaluation of the esophageal morphology and function in subjects with CIP showed a high prevalence of GERD and Barrett's esophagus. Further studies are needed to evaluate whether combined acidic and biliary reflux is able to promote similar histomorphological changes in the CIP, as it is shown distally in patients with Barrett's esophagus.

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.

Frequency, histopathological findings, and clinical significance of cervical heterotopic gastric mucosa (gastric inlet patch): a prospective study in 300 patients

The frequency and clinical significance of heterotopic gastric mucosa in the upper esophagus is not sufficiently known. Heartburn or dysphagia could result from mucin and/or acid production in this area. We undertook a prospective study in 300 patients with special attention of the endoscopist to this area. Moreover, clinical symptoms were determined by questionnaire before performing endoscopy. A total of 33/300 (11%) of patients had at least one histologically proven gastric inlet patch without gender or age preference. In 20/33 (61%) cases, the heterotopic gastric mucosa was classified as mixed type, in 8/33 (24%) as oxyntic, and in 5/33 (15%) as mucoid. Helicobacter pylori was present in none of the cases. There was no significant association to the presence of a hiatal hernia, reflux esophagitis, Barrett's esophagus, or gastric/duodenal ulcer. Moreover, there was no association to the reported grade of heartburn in the upper or lower part of the esophagus, recurrent hoarseness, or dysphagia. When thoroughly performed, heterotopic gastric mucosa is a quite frequent finding in endoscopy of the upper gastrointestinal tract. The presence of this gastric mucosa in the upper third of the esophagus seems to be rarely the cause of clinical symptoms and little prone to complications.

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.

Diagnosis and endoscopic treatment of esophago-bronchial fistula due to gastric heterotopy

Heterotopic gastric mucosa patches are congenital gastrointestinal abnormalities and have been reported to occur anywhere along the gastrointestinal tract from mouth to anus. Complications of heterotopic gastric mucosa include dysphagia, upper gastrointestinal bleeding, upper esophageal ring stricture, adenocarcinoma and fistula formation. In this case report we describe the diagnosis and treatment of the first case of esophago-bronchial fistula due to heterotopic gastric mucosa in mid esophagus. A 40-year old former professional soccer player was referred to our department for treatment of an esophago-bronchial fistula. Microscopic examination of the biopsies taken from the esophageal fistula revealed the presence of gastric heterotopic mucosa. We decided to do a non-surgical therapeutic endoscopic procedure. A sclerotherapy catheter was inserted through which 1 mL of ready to use synthetic surgical glue was applied in the fistula and it closed the fistula opening with excellent results.

Is there an association between Helicobacter pylori in the inlet patch and globus sensation?

AIM: To determine the association between Helicobacter pylori (H. pylori) and globus sensation (GS) in the patients with cervical inlet patch.

METHODS: Sixty-eight patients with esophageal inlet patches were identified from 6760 consecutive patients undergoing upper gastrointestinal endoscopy prospectively. In these 68 patients with cervical inlet patches, symptoms of globus sensation (lump in the throat), hoarseness, sore throat, frequent clearing of the throat, cough, dysphagia, odynophagia of at least 3 mo duration was questioned prior to endoscopy.

RESULTS: Cervical heterotopic gastric mucosa (CHGM) was found in 68 of 6760 patients. The endoscopic prevalence of CHGM was determined to be 1%. H. pylori was identified in 16 (23.5%) of 68 patients with inlet patch. Fifty-three patients were classified as CHGM II. This group included 48 patients with globus sensation, 4 patients with chronic cough and 1 patient with hoarseness. All the patients who were H. pylori (+) in cervical inlet patches had globus sensation.

CONCLUSION: Often patients with CHGM have a long history of troublesome throat symptoms. We speculate that disturbances in globus sensation are like non-ulcer dyspepsia.

Over-expression of cyclooxygenase-2 in endoscopic biopsies of ectopic gastric mucosa

Ectopic gastric mucosa (EGM) is considered to be a congenital condition. Rare cases of adenocarcinoma have been described. There are no data justifying regular biopsies or follow-up. Cyclooxygenase-2 (COX-2) is a protein involved in gastrointestinal tumor development by inhibiting apoptosis and regulating angiogenesis. The aim of this prospective study was to evaluate COX-2 expression in EGM and compare it with normal tissue and Barrett's esophagus. We evaluated 1327 patients. Biopsies were taken from the inlet patch for histological evaluation and from the gastric antrum to assess Helicobacter pylori infection. Biopsies taken from normal esophageal, gastric antrum and body mucosa and Barrett's esophagus were retrieved from a tissue bank. EGM biopsies were evaluated with respect to type of epithelium, presence of H. pylori, and inflammation. COX-2 was detected by immunohistochemistry using the avidin-biotin complex. EGM islets were found in 14 patients (1.1%). Histological examination revealed fundic type epithelium in 58.3% of cases, H. pylori was present in 50% and chronic inflammation in 66.7%. Expression of COX-2 was negative in normal distal esophagus, normal gastric antrum and normal gastric body specimens (10 each). In contrast, EGM presented over-expression of COX-2 in 41.7% of cases and Barrett's esophagus in 90% of cases (P = 0.04 and 0.03, respectively). COX-2 immunoexpression in EGM was not related to gender, age, epithelium type, presence of inflammation or intestinal metaplasia, H. pylori infection, or any endoscopic finding. Our results demonstrate up-regulation of COX-2 in EGM, suggesting a possible malignant potential of this so-called harmless mucosa.

Prevalence of endoscopically identified heterotopic gastric mucosa in the proximal esophagus: endoscopist dependent?

GOALS

The aim of this study is to determine the prevalence of heterotopic gastric mucosa in the proximal esophagus (HGMPE) and whether thorough endoscopic search may influence such prevalence.

BACKGROUND

Heterotopic gastric mucosa in the esophagus (sometimes known as inlet patch) refers to a discrete area of gastric mucosa, with a spherical or ellipsoid configuration, that is typically located in the proximal esophagus. The prevalence of endoscopically diagnosed HGMPE varies from 0.1% to 10%. Endoscopic detection may be difficult as HGMPE is often located at or just below the upper esophageal sphincter. It might be associated with severe complications such as bleeding, perforation, fistula, and stricture formation, in addition to the development of adenocarcinoma.

STUDY

During a 2-year period, 455 consecutive patients with various gastrointestinal complaints underwent esophagogastroduodenoscopy by a single endoscopist (group 1). This endoscopist paid special attention to detecting HGMPE by thoroughly examining the proximal esophagus upon withdrawal of the endoscope. During the same period of time, endoscopy reports of 472 patients who underwent esophagogastroduodenoscopy in the same hospital by 3 other endoscopists were retrospectively reviewed (group 2). These endoscopists were aware of the existence of the HGMPE and reported that the presence of HGMPE would be included as an endoscopic finding in their reports.

RESULTS

In the first group, HGMPE was identified in 12 out of 455 patients (2.6%). Whereas in the second group, only 2 out of 472 patients (0.4%) had reports identifying HGMPE (P<0.01).

CONCLUSIONS

Endoscopic detection of HGMPE is influenced by the endoscopist's thorough search of this entity, and thus, more time devoted to such a search may lead to higher detection rates.