Metabolic syndrome increases risk of Barrett esophagus in the absence of gastroesophageal reflux: an analysis of SEER-Medicare Data

Investigating causal links between gastroesophageal reflux disease and essential hypertension

Gastroesophageal reflux disease (GERD) is a prevalent global health concern with a rising incidence. Various risk factors, including obesity, hiatal hernia, and smoking, contribute to its development. Recent research suggests associations between GERD and metabolic syndrome, cardiac diseases, and hypertension (HTN). Mechanisms linking GERD to HTN involve autonomic dysfunction, inflammatory states, and endothelial dysfunction. Furthermore, GERD medications such as proton-pump inhibitors may impact blood pressure regulation. Conversely, antihypertensive medications like beta-blockers and calcium channel blockers can exacerbate GERD symptoms. While bidirectional causality exists between GERD and HTN, longitudinal studies are warranted to elucidate the precise relationship. Treatment of GERD, including anti-reflux surgery, may positively influence HTN control. However, the interplay of lifestyle factors, comorbidities, and medications necessitates further investigation to comprehensively understand this relationship. In this editorial, we comment on the article published by Wei et al in the recent issue of the World Journal of Clinical Cases. We evaluate their claims on the causal association between GERD and HTN.

The causal associations of circulating lipids with Barrett's Esophagus and Esophageal Cancer: a bi-directional, two sample mendelian randomization analysis

OBJECTIVE

The causal associations of circulating lipids with Barrett's Esophagus (BE) and Esophageal Cancer (EC) has been a topic of debate. This study sought to elucidate the causality between circulating lipids and the risk of BE and EC.

METHODS

We conducted two-sample Mendelian randomization (MR) analyses using single nucleotide polymorphisms (SNPs) of circulating lipids (n = 94,595 - 431,167 individuals), BE (218,792 individuals), and EC (190,190 individuals) obtained from the publicly available IEU OpenGWAS database. The robustness and reliability of the results were ensured by employing inverse-variance weighted (IVW), weighted median, MR-Egger, and MR-PRESSO methods. The presence of horizontal pleiotropy, heterogeneities, and stability of instrumental variables were assessed through MR-Egger intercept test, Cochran's Q test, and leave-one-out sensitivity analysis. Additionally, bidirectional MR and multivariable MR (MVMR) were performed to explore reverse causality and adjust for known confounders, respectively.

RESULTS

None of the testing methods revealed statistically significant horizontal pleiotropy, directional pleiotropy, or heterogeneity. Univariate MR analyses using IVW indicated a robust causal relationship between increased triglycerides and BE (odds ratio [OR] = 1.79, p-value = 0.009), while no significant association with EC was observed. Inverse MR analysis indicated no evidence of reverse causality in the aforementioned outcomes. In MVMR analyses, elevated triglycerides (TRG) were significantly and positively associated with BE risk (OR = 1.79, p-value = 0.041).

CONCLUSION

This MR study suggested that genetically increased triglycerides were closely related to an elevated risk of BE, potentially serving as a biomarker for the diagnosis of BE in the future.

Prospective clinical cohort study: low incidence of Barrett esophagus but high rate of reflux disease at 5-year follow-up after sleeve gastrectomy versus Roux-en-Y gastric bypass

BACKGROUND

Gastroesophageal reflux disease seems more frequent after laparoscopic sleeve gastrectomy (LSG) than Roux-en-Y gastric bypass (LRYGB). Retrospective case series have raised concerns about a high incidence of Barrett esophagus (BE) after LSG.

OBJECTIVE

This prospective clinical cohort study compared the incidence of BE ≥5 years after LSG and LRYGB.

SETTING

St. Clara Hospital, Basel, and University Hospital, Zürich, Switzerland.

METHODS

Patients were recruited from 2 bariatric centers where preoperative gastroscopy is standard practice and LRYGB is preferred for patients with preexisting gastroesophageal reflux disease. At follow-up ≥5 years after surgery, patients underwent gastroscopy with quadrantic biopsies from the squamocolumnar junction and metaplastic segment. Symptoms were assessed using validated questionnaires. Wireless pH measurement assessed esophageal acid exposure.

RESULTS

A total of 169 patients were included, with a median 7.0 ± 1.5 years after surgery. In the LSG group (n = 83), 3 patients had endoscopically and histologically confirmed de novo BE; in the LRYGB group (n = 86), there were 2 patients with BE, 1 de novo and 1 preexisting (de novo BE, 3.6% versus 1.2%; P = .362). At follow-up, reflux symptoms were reported more frequently by the LSG group than by the LRYGB group (51.9% versus 10.5%). Similarly, moderate-to-severe reflux esophagitis (Los Angeles grade B-D) was more common (27.7% versus 5.8%) despite greater use of proton pump inhibitors (49.4% versus 19.7%), and pathologic acid exposure was more frequent in patients who underwent LSG than in patients who underwent LRYGB.

CONCLUSIONS

After at least 5 years of follow-up, a higher incidence of reflux symptoms, reflux esophagitis, and pathologic esophageal acid exposure was found in patients who underwent LSG compared with patients who underwent LRYGB. However, the incidence of BE after LSG was low and not significantly different between the 2 groups.

Endoscopic Evaluation of De Novo Esophagitis and Barrett's Esophagus, 5 Years After Sleeve Gastrectomy

PURPOSE

Sleeve gastrectomy (SG) is the most common bariatric procedure worldwide. It has been reported that there is a strong association between SG and the development of gastroesophageal reflux disease (GERD) and Barrett's esophagus (BE). This study was conducted to evaluate esophagogastroduodenoscopy (EGD) findings in patients with a history of SG with more than 5-year follow-up.

METHODS

This is a retrospective cohort study of prospectively maintained database. Inclusion criteria included patients who underwent SG between April 2015 and March 2016, aged 18 and above, BMI ≥ 40 kg/m². Patients with 5 years of follow-up were invited to take part in the study and underwent EGD and biopsy.

RESULTS

One hundred twenty-six patients were recruited with a mean age of 44.6 ± 11.1 years. After a 5-year follow-up, there were 31 (29.5%) patients with reflux esophagitis. The grades of GERD were A, B, and C in 16 (15.2), 12 (11.4), and 3 (2.9%) patients, respectively. Incidence of BE was 5.7% after 5 years from SG. There was a 16.6% lost to follow-up at 5 years after SG.

CONCLUSION

The diagnosis and severity of GERD and the search for BE justify endoscopic surveillance in all long-term post-sleeve patients, regardless of reflux symptoms.

Induction and maintenance of healing in erosive esophagitis in the United States

INTRODUCTION

Erosive esophagitis (EE) occurs when refluxate from the stomach causes T-lymphocyte infiltration of the esophageal mucosa, resulting in mucosal breaks. Currently, therapy with proton-pump inhibitors (PPIs) is the standard treatment for EE in the United States, but few comprehensive reviews exist on the efficacy of PPIs in US populations. Here, we present the most contemporary, thorough analysis of PPI efficacy rates, and identify and characterize patient subgroups at risk for poor healing outcomes.

AREAS COVERED

We searched the literature to identify studies reporting rates of endoscopic healing and maintained healing of EE with PPI therapies in the US and found a paucity of recent evidence and real-world evidence. Twenty-two studies from 2009 and earlier were included in the final dataset.

EXPERT OPINION

Rates of EE healing with PPIs were highest after 8 weeks of treatment, with over 80% of patients in most treatment arms demonstrating endoscopic healing, compared to lower efficacy (<80%) at 4 weeks. Rates of maintained healing with PPIs at 6 and 12 months were mostly lower than 80%, although the data were limited. Symptomatic patients and those with severe EE were less likely to achieve healing. Obese patients experienced similar healing rates as non-obese patients.

Visceral obesity with and without metabolic syndrome: incidence and clinical impact in esophageal adenocarcinoma treated with curative intent

Visceral obesity (VO) and metabolic syndrome (MetS) are risk factors for esophageal adenocarcinoma (EAC); however, their impact on operative and oncological outcomes is unclear. The aim of this study was to determine the incidence of VO and MetS among patients with EAC, and to assess their independent impact on operative and oncological outcomes. A total of 454 consecutive patients undergoing treatment with curative intent were studied. Total, subcutaneous, visceral fat area (VFA), and lean body mass (LBM) were measured by computed tomography pretreatment, with VO defined as VFA >163.8cm2 for men and 80.1cm2 for women. MetS was defined per the ATPIII definition. Multivariable logistic and Cox proportional hazards regression were utilized to determine independent predictors of oncologic and operative outcomes. A total of 227 patients (50.0%) had VO. A total of 134 (30%) overall had MetS, 44% in the VO cohort. VO was associated with Barrett's esophagus (P = 0.002) and lower cT (P = 0.006) and cN stage (P = 0.011), and improved disease-specific (P = 0.021) and overall survival (P = 0.012). No survival benefit existed for patients with VO who also had MetS. For operative complications, neither VO nor MetS increased the severity of complications, or mortality. However, VO was significantly (P = 0.035) associated with anastomotic leak and pneumonia (P = 0.037). MetS alone did not increase complication risk. VO increases specific major operative complications with no increase in mortality. VO improved survival, mainly relating to earlier stage disease; however, co-existent MetS abrogated this benefit. These seemingly paradoxical outcomes highlight manageable and potentially targetable perioperative challenges in the context of an overall favorable oncologic vista.

Risk factors for Barrett's esophagus: Recent advances

Esophageal adenocarcinoma (EAC) is the most common malignant tumor of the esophagus in the West. During the past few decades, its morbidity has been increasing in China. Barrett's esophagus (BE) is defined as the replacement of normal squamous epithelium in the lower esophagus by metaplasia of columnar epithelium. BE is closely related to the occurrence of EAC. Knowledge regarding the risk factors for the occurrence and development of BE is of great significance for early screening and diagnosis of BE and prevention of EAC. In this paper, we review the clinical, demographics-related, lifestyle-related, and medications-related risk factors for BE to provide more valuable scientific evidence for the prevention and treatment of BE.

Esophageal adenocarcinoma phenotypes and risk factors

PURPOSE OF REVIEW

The incidence of esophageal adenocarcinoma (EAC) has increased significantly over the last several decades. The majority of EAC patients present without a prior history of Barrett's esophagus (BE). As a result, endoscopic surveillance has made a suboptimal impact on EAC survival. These concerns raise serious question whether the time has come to take a different direction. The aim of this article is to review evolving evidence of EAC phenotypes and risk factors.

RECENT FINDINGS

A recent study has identified two phenotypes of EAC based on the presence or absence of intestinal metaplasia (IM) in the background of the tumor (BE/IM and non-BE/IM). The study found that one-half of patients with EAC have the non-BE/IM phenotype, which is associated with more aggressive behavior and worse survival. A retrospective review demonstrates that the proportion of the two phenotypes has been stable over the last decades. Similarly, the increasing incidence of EAC cannot be explained by an increased frequency of new, unique risk factors but rather by a higher prevalence of already known risk factors. Emerging data also demonstrates that, whereas reflux symptoms are an unreliable feature for screening regardless of phenotype, the absence of reflux symptoms is more common for the non-BE/IM. Differences in the degree of genomic methylation and immune response might explain the two phenotypes at a genomic level.

SUMMARY

EAC phenotypes have implications for tumor behavior and phenotypic differences might underlie our suboptimal screening efforts. Future screening efforts should not uniformly rely on reflux symptoms as a prerequisite for screening and should consider alternatives to the current screening strategy.

Metabolic syndrome is associated with higher rate of gastroesophageal reflux disease: a meta-analysis

BACKGROUND AND AIM

Gastroesophageal reflux disease (GERD) seriously lowers the quality of life of patients, and its prevalence has gradually increased in recent years. Some studies have showed that metabolic syndrome (MetS) is related to GERD, but the results remain controversial. This study explored the relationship between MetS and GERD through systematic retrieval and analysis of published studies.

METHODS

Retrieve related research from PubMed, Web of Science, and Cochrane Library. Including cohort studies that compare the prevalence of GERD between patients with MetS and patients without, and case-control studies or cross-sectional studies that compare the prevalence of MetS between patients with GERD and patients without. In addition to analyzing the relationship between MetS and GERD, individual metabolic components are also analyzed. Use a random effects model (DerSimmonian and Laird) to merge the odd ratio (OR). Cochran's Q test and Higgins' I-squared statistic were performed to assess heterogeneity. Publication bias was assessed by Egger's test.

KEY RESULTS

A total of 103,048 patients from 15 studies were included. The combined results suggest that MetS is a risk factor of GERD (OR: 1.66, 95%CI: 1.38-1.99). Among the individual metabolic components, abdominal obesity (OR: 1.42, 95%CI: 1.22-1.64), hypertriglyceridemia (OR: 1.50, 95%CI: 1.27-1.78), hyperglycemia (OR: 1.31, 95%CI: 1.07-1.61), and hypertension (OR: 1.19, 95%CI: 1.07-1.33) are risk factors of GERD.

CONCLUSIONS AND INFERENCES

MetS is a risk factor of GERD, and among the abnormal metabolic components that establish the diagnosis of MetS, abdominal obesity, hypertriglyceridemia, hyperglycemia, and hypertension are risk factors of GERD.

Metabolic Dysfunction-Associated Fatty Liver Disease Increases the Risk of Gastroesophageal Reflux Symptoms

OBJECTIVE

The present study aimed to explore the relationship between metabolic dysfunction-associated fatty liver disease (MAFLD) and gastroesophageal reflux symptoms (GERS).

METHODS

The present study was a cross-sectional observational study. The study population was 3002 subjects from a single hospital who underwent a health checkup from September 1, 2019, to December 31, 2020. The diagnosis of MAFLD was based on the diagnosis of fatty liver in the subject by ultrasound or computed tomography (CT) and the presence of one of the following conditions: overweight or obesity (body mass index [BMI] ≥ 23), type 2 diabetes mellitus, and metabolic abnormalities. The subjects were divided into the GERS group (n = 305) and the non-GERS group (n = 2697) based on the presence or absence of GERS, based on the GerdQ score.

RESULTS

The prevalence of MAFLD was significantly higher in the GERS group than in the non-GERS group (p = 0.001). In the univariate analysis of risk factors for GERS, MAFLD was identified as a risk factor for GERS (OR 1.5; 95% CI 1.176-1.913; p = 0.001). With adjustment of confounding factors such as BMI, waist circumference, lipid levels, and blood pressure, the correlation between MAFLD and GERS was attenuated but still significant (OR 1.408; 95% CI 1.085-1.826; p = 0.010).

CONCLUSION

MAFLD might be an independent risk factor for GERS.

Endoscopic prediction of submucosal invasion in Barrett's cancer with the use of artificial intelligence: a pilot study

BACKGROUND

The accurate differentiation between T1a and T1b Barrett's-related cancer has both therapeutic and prognostic implications but is challenging even for experienced physicians. We trained an artificial intelligence (AI) system on the basis of deep artificial neural networks (deep learning) to differentiate between T1a and T1b Barrett's cancer on white-light images.

METHODS

Endoscopic images from three tertiary care centers in Germany were collected retrospectively. A deep learning system was trained and tested using the principles of cross validation. A total of 230 white-light endoscopic images (108 T1a and 122 T1b) were evaluated using the AI system. For comparison, the images were also classified by experts specialized in endoscopic diagnosis and treatment of Barrett's cancer.

RESULTS

The sensitivity, specificity, F1 score, and accuracy of the AI system in the differentiation between T1a and T1b cancer lesions was 0.77, 0.64, 0.74, and 0.71, respectively. There was no statistically significant difference between the performance of the AI system and that of experts, who showed sensitivity, specificity, F1, and accuracy of 0.63, 0.78, 0.67, and 0.70, respectively.

CONCLUSION

This pilot study demonstrates the first multicenter application of an AI-based system in the prediction of submucosal invasion in endoscopic images of Barrett's cancer. AI scored equally to international experts in the field, but more work is necessary to improve the system and apply it to video sequences and real-life settings. Nevertheless, the correct prediction of submucosal invasion in Barrett's cancer remains challenging for both experts and AI.

Risk Factor Profiles Can Distinguish Esophageal Adenocarcinoma From Barrett's Esophagus

INTRODUCTION

It is assumed that screening risk factors for Barrett's esophagus (BE) and prevalent esophageal adenocarcinoma (EAC) are the same.

METHODS

A matched case-control study comparing risk factors between EAC and BE was performed.

RESULTS

In 1,356 patients (678 with EAC and 678 with BE), heartburn (52.7%), diabetes, hyperlipidemia, hypertension, nonalcoholic steatohepatitis, and metabolic syndrome were less common in EAC (52.7, 29.2, 45.7, 48.2, 12, and 28.5%, resp.) compared with BE (84.5, 37.6, 82.2, 64.6, 18.4, and 44.1%, P < 0.01). Mean alanine aminotransferase and HgA1c levels were also significantly lower in EAC compared with BE.

DISCUSSION

Optimal strategies for screening for prevalent EAC may be different than that for BE.

Sex Differences in the Risk of Barrett's Esophagus Associated With the Metabolic Effects of Obesity

GOAL

The goal of this study was to determine if there is an association between the insulin-insulin-like growth factor axis, the metabolic syndrome (MetS), type 2 diabetes mellitus and risk of Barrett's esophagus (BE), and if these associations are modified by sex.

BACKGROUND

BE is more common in males. Gastroesophageal reflux disease, the major risk factor for BE occurs at similar frequencies in both sexes, suggesting that sex-related factors such as the metabolic effects of abdominal obesity may be important in the causation of BE.

MATERIALS AND METHODS

A structured interview, anthropometric measures, and fasting blood were collected within a population-based case-control study. We recruited 227 BE cases (70% male) and 241 population controls, frequency matched by age and sex. We estimated odds ratios (ORs) and 95% confidence intervals (CIs) for association with BE using multivariable logistic regression models.

RESULTS

Hyperinsulinemia (highest vs. lowest tertile, OR=1.9; 95% CI: 1.2-3.1), Homeostatic Model Assessment of Insulin Resistance (OR=1.9; 95% CI: 1.2-3.1) and the MetS (OR=1.8; 95% CI: 1.2-2.6) were independently associated with an increased risk of BE. With each additional MetS criterion, there was a 20% increased risk of BE (OR=1.2; 95% CI: 1.0-1.4). When stratified by sex, these associations were found in males but not females. We found no association with serum measures of insulin-like growth factors or interleukin-6 and risk of BE.

CONCLUSION

Hyperinsulinemia, insulin resistance, and the MetS are associated with the risk of BE in males but not females, suggesting these factors may contribute to the higher prevalence of BE in males.

The relationship between metabolic syndrome and increased risk of Barrett's esophagus: an updated systematic review and meta-analysis

BACKGROUND

The relationship between metabolic syndrome (MetS) and Barrett's esophagus (BE) is still a challenging issue, and inconsistent results have been reported in different studies. Therefore, this study was conducted to determine the relationship between MetS and BE.

METHODS

In this study, we followed the MOOSE protocol and results were reported according to the PRISMA guidelines. All study steps were performed independently by two authors. If necessary, the dispute was resolved by consultation with a third author. The search strategy is designed to find published studies. Comprehensive search was done in the following databases until July 2019: Cochrane Library, PubMed/Medline, Web of Science, Science Direct, EMBASE, Scopus, CINAHL, EBSCO, and Google Scholar search engine. All analyses were performed using Comprehensive Meta-Analysis Software Ver.2, while p-value lower than 0.05 was considered significant.

RESULTS

In 14 studies with a sample size of 108,416, MetS significantly increased the risk of BE (OR = 1.354; 95% CI: 1.145-1.600; P < 0.001; Heterogeneity: I2 = 81.95%; P < 0.001). Sensitivity analysis by omitting one study showed that overall estimates are still robust. Subgroup analysis was significant for continent (P < 0.001) and MetS diagnostic criteria (P = 0.043), but was not significant for variables of study type (P = 0.899), study setting (P = 0.115), control groups (P = 0.671) and quality of studies (P = 0.603). The Begg (P = 0.912) and Egger's (P = 0.094) tests were not significant; therefore, the publication bias did not play a role in the results.

CONCLUSION

MetS increases the risk of BE compared to control groups. The results of this study can help health practitioners by identifying a treatable risk factor for the most important risk factor for esophageal carcinoma (ie, BE). Future studies should examine whether treatment for MetS reduces the risk of BE.

Independent association of obstructive sleep apnea with Barrett's esophagus

BACKGROUND AND AIM

Current guidelines suggest screening at-risk groups of patients for Barrett's esophagus (BE), a precursor to esophageal cancer. Although BE and obstructive sleep apnea (OSA) have common risk factors, including elevated body mass index and gastroesophageal reflux disease (GERD), the relationship between these two conditions has not been well established.

METHODS

Retrospectively, all patients who had undergone a polysomnography and esophagogastroduodenoscopy at West Virginia University Hospital from 2013 to 2018 were identified and divided into groups on the basis of the presence or absence of OSA. Clinical course and procedure reports were reviewed to identify relevant variables.

RESULTS

One thousand ninety-one patients met inclusion criteria; 60.9% were female, and mean age of participants was 53.5 years. Univariate analysis revealed that male gender, age, diagnosis of OSA, severity of OSA, and a clinical diagnosis of GERD were associated with BE (P values < 0.05). Multiple logistic regression incorporating age, sex, clinical diagnosis of GERD, smoking history, body mass index, Helicobacter pylori status, and presence of hiatal hernia was utilized. Patients with OSA had an increased risk of BE than had those without OSA (P < 0.001, odds ratio 3.26 [1.72-6.85]). The risk increased with increasing severity of OSA, categorized in apnea-hypopnea index increments of 10.

CONCLUSION

Obstructive sleep apnea is associated with BE, a relationship that is independent of other known risk factors. Additionally, this risk increases with increasing severity of OSA. Future efforts should determine if patients with severe OSA need to be screened for BE due to its potential for causing esophageal cancer.

Diabetes in relation to Barrett's esophagus and adenocarcinomas of the esophagus: A pooled study from the International Barrett's and Esophageal Adenocarcinoma Consortium

BACKGROUND

Diabetes is positively associated with various cancers, but its relationship with tumors of the esophagus/esophagogastric junction remains unclear.

METHODS

Data were harmonized across 13 studies in the International Barrett's and Esophageal Adenocarcinoma Consortium, comprising 2309 esophageal adenocarcinoma (EA) cases, 1938 esophagogastric junction adenocarcinoma (EGJA) cases, 1728 Barrett's esophagus (BE) cases, and 16,354 controls. Logistic regression was used to estimate study-specific odds ratios (ORs) and 95% CIs for self-reported diabetes in association with EA, EGJA, and BE. Adjusted ORs were then combined using random-effects meta-analysis.

RESULTS

Diabetes was associated with a 34% increased risk of EA (OR, 1.34; 95% CI, 1.00-1.80; I2  = 48.8% [where 0% indicates no heterogeneity, and larger values indicate increasing heterogeneity between studies]), 27% for EGJA (OR, 1.27; 95% CI, 1.05-1.55; I2  = 0.0%), and 30% for EA/EGJA combined (OR, 1.30; 95% CI, 1.06-1.58; I2  = 34.9%). Regurgitation symptoms modified the diabetes-EA/EGJA association (P for interaction = .04) with a 63% increased risk among participants with regurgitation (OR, 1.63; 95% CI, 1.19-2.22), but not among those without regurgitation (OR, 1.03; 95% CI, 0.74-1.43). No consistent association was found between diabetes and BE.

CONCLUSIONS

Diabetes was associated with increased EA and EGJA risk, which was confined to individuals with regurgitation symptoms. Lack of an association between diabetes and BE suggests that diabetes may influence progression of BE to cancer.

Obesity-Related Digestive Diseases and Their Pathophysiology

Obesity is a growing medical and public health problem worldwide. Many digestive diseases are related to obesity. In this article, the current state of our knowledge of obesity-related digestive diseases, their pathogenesis, and the medical and metabolic consequences of weight reduction are discussed. Obesity-related digestive diseases include gastroesophageal reflux disease, Barrett’s esophagus, esophageal cancer, colon polyp and cancer, nonalcoholic fatty liver disease, hepatitis C-related disease, hepatocellular carcinoma, gallstone, cholangiocarcinoma, and pancreatic cancer. Although obesity-related esophageal diseases are associated with altered mechanical and humoral factors, other obesity-related digestive diseases seem to be associated with obesity-induced altered circulating levels of adipocytokines and insulin resistance. The relationship between functional gastrointestinal disease and obesity has been debated. This review provides a comprehensive evaluation of the obesity-related digestive diseases, including pathophysiology, obesity-related risk, and medical and metabolic effects of weight reduction in obese subjects.

Barrett’s oesophagus: Current controversies

Oesophageal adenocarcinoma is rapidly increasing in Western countries. This tumour frequently presents late in its course with metastatic disease and has a very poor prognosis. Barrett’s oesophagus is an acquired condition whereby the native squamous mucosa of the lower oesophagus is replaced by columnar epithelium following prolonged gastro-oesophageal reflux and is the recognised precursor lesion for oesophageal adenocarcinoma. There are multiple national and society guidelines regarding screening, surveillance and management of Barrett’s oesophagus, however all are limited regarding a clear evidence base for a well-demonstrated benefit and cost-effectiveness of surveillance, and robust risk stratification for patients to best use resources. Currently the accepted risk factors upon which surveillance intervals and interventions are based are Barrett’s segment length and histological interpretation of the systematic biopsies. Further patient risk factors including other demographic features, smoking, gender, obesity, ethnicity, patient age, biomarkers and endoscopic adjuncts remain under consideration and are discussed in full. Recent evidence has been published to support earlier endoscopic intervention by means of ablation of the metaplastic Barrett’s segment when the earliest signs of dysplasia are detected. Further work should concentrate on establishing better risk stratification and primary and secondary preventative strategies to reduce the risk of adenocarcinoma of the oesophagus.

A review of the impact of obesity on common gastrointestinal malignancies

Obesity is a global pandemic and is a well-recognized risk factor for various gastrointestinal diseases. The prevalence of obesity is increasing across all age groups. There is an emergent need for focused guidelines aimed at reducing the incidence, prevalence, and associated risks of obesity. The impact of obesity on gastrointestinal cancers being multifactorial adversely influences the associated risk, disease course, prognosis, and overall survival. We have summarized the current literature highlighting the association between obesity and common gastrointestinal cancers, with specific focus on esophageal adenocarcinoma, colon cancer, hepatocellular cancer, cholangiocarcinoma, and pancreatic malignancies.

Is Obesity Associated with Barrett's Esophagus and Esophageal Adenocarcinoma?

Barrett's esophagus is a premalignant condition portending increased risk of esophageal adenocarcinoma. Given the significant morbidity and mortality of esophageal adenocarcinoma, identification of risk factors for Barrett's esophagus and esophageal adenocarcinoma is crucial. There are a plethora of studies investigating the relationship of obesity with these pathologies. Recent studies reveal that this relationship may specifically be with central adiposity. Increased cell turnover and eventual carcinogenesis is likely precipitated by increased intragastric pressure but also is affected by the complex interplay of increased insulin resistance in patients with increased fat tissue. Further studies are warranted to evaluate if weight loss can decrease progression of Barrett's esophagus.

Metabolic syndrome and risk of esophageal adenocarcinoma in elderly patients in the United States: An analysis of SEER-Medicare data

BACKGROUND

Metabolic syndrome (MetS) is associated with cancer risk and increases the risk of Barrett esophagus, which is the precursor lesion of esophageal adenocarcinoma (EA), primarily in the absence of gastroesophageal reflux disease (GERD). However, to the authors' knowledge, little is known regarding whether MetS is associated with the risk of EA.

METHODS

Using the Surveillance, Epidemiology, and End Results (SEER)-Medicare-linked database, the authors evaluated whether MetS was associated with EA. A total of 3167 cases of EA were compared with individually matched population controls (5:1); a subset of 575 EA cases were able to be individually matched with 575 Barrett esophagus controls. MetS was defined using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes in the period 1 to 3 years before the diagnosis of EA or control selection. Unconditional logistic regression was used to estimate adjusted odds ratios and 95% confidence intervals. Potential effect modification by GERD symptoms and sex was examined in stratified models.

RESULTS

EA was found to be significantly associated with MetS (odds ratio, 1.16; 95% confidence interval, 1.06-1.26) compared with population controls. In males, the association was restricted to those individuals without prior GERD; however, in females, MetS was found to be associated with EA regardless of GERD status. Effect modification by sex was observed (P for interaction = .01). MetS was not found to be associated with EA risk when compared with Barrett esophagus controls.

CONCLUSIONS

In this older population, MetS was found to be associated with an increased risk of EA in males without GERD and females regardless of GERD status. Given the lack of an association when compared with Barrett esophagus controls, MetS may impact EA risk by primarily increasing the risk of the precursor lesion, Barrett esophagus. Cancer 2017;123:657-665. © 2016 American Cancer Society.

Pathogenesis and progression of oesophageal adenocarcinoma varies by prior diagnosis of Barrett's oesophagus

Background:

The absolute risk of oesophageal adenocarcinoma (EA) among individuals with Barrett's oesophagus (BE) is low and a majority of EA cases are diagnosed among individuals with no prior BE diagnosis. To ensure that insights from EA case–control studies are transferable to clinical management of BE populations, we conducted a case–case study to compare the clinical presentation, medical history and survival of EA cases with and without a prior BE diagnosis in the Surveillance, Epidemiology and End Results Medicare database.

Methods:

Eligible EA cases were diagnosed at age ⩾68 years during 1994–2009. There were 5271 EA cases in this study, 87% of which did not have a prior diagnosis of BE (EA-no prior BE).

Results:

Multivariable case–case comparisons evidenced adverse associations of GERD, ever cigarette smoking, hypertension, dyslipidemia, weight loss, peptic ulcer and irritable bowel disease each in EA-prior BE compared with EA-no prior BE. Obesity, metabolic syndrome, impaired fasting glucose and diabetes did not differ between groups. EA-prior BE cases were diagnosed with less advanced disease, were more likely to undergo surgery and less likely to receive chemotherapy and radiotherapy, and had better overall mean survival (2.5 vs 1.4 years). This survival advantage persisted in the multivariable Cox model (HR=0.69, 95%CI: 0.60, 0.78), despite adjustment for many factors including stage, grade and clinical interventions.

Conclusions:

This study provides evidence that EA cases occurring among individuals previously diagnosed with BE are different from the large majority of EA cases that occur without a prior BE diagnosis. Regardless of whether these differences emanate from aetiology, biology and/or selection biases, they underscore the importance of a prudent approach in using knowledge from EAC case–control studies in the management of BE populations.

Metabolic syndrome is associated with increased risk of Barrett esophagus: A meta-analysis

BACKGROUND

Barrett esophagus (BE) is considered precursor condition of esophageal adenocarcinoma. Its incidence and prevalence are increasing in general population. Studies reported that metabolic syndrome (MS) or diabetes mellitus (DM) is related to increased risk of BE. Current study was to assess and better understand the relationship between MS /DM and BE.

METHODS

Electronic search was conducted in the database Pubmed/Medline (-December, 2015), Embase (-December, 2015), Cochrane Library (-December, 2015), and Web of Knowledge (-December, 2015). Studies included were assessed with summary odds ratios (ORs) with 95% confidence intervals (CIs) and compared exposure group with control group. The heterogeneity was examined by the funnel plot and the Egger's test. Subgroup analyses and sensitive analyses were performed for the detection of possible heterogeneity and impact on stability of analysis results.

RESULTS

Twelve publications met the criteria and included 355,311 subjects were analyzed. The pooled results showed MS was closely associated with increased risk of BE (OR = 1.23; 95%CI 1.03-1.47; P = 0.024), and yet DM did not significantly increase the risk of BE (OR = 1.07; 95%CI 0.82-1.38; P = 0.627). Substantial heterogeneities were detected. No significant publication bias was detected by Egger's test (P = 0.23).

CONCLUSIONS

Based on the results of current meta-analysis, MS is associated with increased risk of BE. Further long-term follow-up prospective study needs to verify the current results, and definite pathophysiological mechanism needs to be further investigated and clearly elucidated.

Determination of risk for Barrett's esophagus and esophageal adenocarcinoma

PURPOSE OF REVIEW

The incidence of esophageal adenocarcinoma and its precursor, Barrett's esophagus, have increased greatly over the past 40 years and continue to rise. This report summarizes the most recent data on the risk factors for Barrett's esophagus and esophageal adenocarcinoma.

RECENT FINDINGS

Other factors, highly correlated with increasing trends for obesity, are the dominant driver of the increase in incidence of esophageal adenocarcinoma, interacting with gastroesophageal reflux disease symptoms. Abdominal obesity, independently of gastroesophageal reflux disease symptoms, is associated with increased risk of Barrett's esophagus and this association is likely mediated by high levels of leptin and insulin. Use of aspirin, nonsteroidal anti-inflammatory drugs, statins, and proton pump inhibitors are associated with a reduced risk of Barrett's esophagus as well as lower risk of neoplastic progression in patients with Barrett's esophagus. An increasing number of genetic loci have been associated with risk of Barrett's esophagus and esophageal adenocarcinoma.

SUMMARY

Recent advances in identifying risk factors and reporting of more precise estimates of effect for the main risk factors will positively impact clinical risk stratification efforts for Barrett's esophagus and esophageal adenocarcinoma. Large pooling studies are underway to derive and validate reliable clinical risk models.

[Specific features of gastroesophageal reflux disease associated with obesity and overweight]

AIM

To reveal the specific features of gastroesophageal reflux disease (GERD) associated with obesity and overweight, by investigating the clinical and endoscopic manifestations of the disease, 24-hour pH-metry scores, and leptin levels.

SUBJECTS AND METHODS

A total of 131 patients with GERD were examined. The data about complaints and those from life and medical histories were collected; anthropometric measurements and the results of blood biochemical tests, esophagoduodenoscopy (EPDS), and pH-metry were assessed; and the serum levels of leptin and its receptor were estimated. The patients were allocated into a study group (104 obese and/or overweight patients) and a comparison one (27 normal weight people).

RESULTS

Waist circumference, hip circumference, and blood glucose levels proved to be statistically significantly higher in the study group (p<0.00000, p<0.00002, and p<0.02, respectively). The obese patients were found to have a statistically significantly higher level of leptin and a lower level of its soluble receptors: the median leptin levels were 30.42 (13.42-45.62) ng/ml in the study group and 5.47 (3.35-7.68) ng/ml in the comparison group; the median levels of the receptors were 18.83 (14.98-25.11) ng/ml and 30.93 (24.68-33.53) ng/ml, respectively). This group showed a moderate negative correlation between these indicators (rs=-0.451; p<0.0004). The study group displayed higher pH values in the gastric cardia and body (p<0.05 and p<0.04, respectively). The mucosal contact time with the refluxate having with a low pH value (<4) in the above segments turned out to be longer in the comparison group (p<0.05). There were weight-independent relationships of the leptin level to its spread, aggressiveness quotient, to the highest pH value in the gastric cardia and body, and to the mucosal contact time with the refluxate having a pH below 4.0 (rs=0.543; p<0.006; rs=0.432; p<0.04; rs=0.431; p<0.04; rs=-0.450; p<0.03, respectively), leptin receptors with a pH ratio in the gastric cardia and body, to the number of reflux episodes longer than 5 minutes in the esophagus, and to the De Meester index for this indicator (rs=0.471; p<0.04; rs=-0.455; p<0.04; rs=-0,454; p<0.04, respectively).

CONCLUSION

Obese and overweight patients develop GERD in the presence of leptin resistance and biliary tract disease, which determines the specific features of the disease (alkaline or mixed refluxate) and the need for individualized therapy.

Metabolic syndrome in relation to Barrett's esophagus and esophageal adenocarcinoma: Results from a large population-based case-control study in the Clinical Practice Research Datalink

Gastroesophageal reflux disease (GERD) causes local chronic inflammation that increases risks of Barrett's esophagus (BE) and esophageal adenocarcinoma (EA), yet symptomatic GERD is absent in approximately half of all such patients. Obesity exacerbates GERD and is also a component of metabolic syndrome (MetS). We evaluated the hypothesis that MetS is a GERD-independent mechanism by which obesity is associated with increased risks of BE and EA using data from the UK Clinical Practice Research Datalink. BE cases (n=10,215) and EA cases (n=592) were each individually matched to five population controls based on age, sex, and general practice. MetS was defined as occurrence of at least three of the following: obesity, type 2 diabetes, hypertension, and high cholesterol. Odds ratios (OR) and 95% confidence intervals (CI) were estimated using conditional logistic regression. MetS was marginally associated with BE (OR=1.12, 95%CI 1.00-1.25). Similar effects were found for the individual component factors of obesity, hypertension, and high cholesterol. History of GERD modified the association (P-effect modification <1E-5), with the MetS-BE association confined to patients without a history of GERD (OR=1.33, 95%CI 1.12-1.58). No association between MetS and risk of EA was detected in the main or stratified analyses. In this large population-based case-control study, individuals with MetS had a marginally increased risk of BE in the absence of GERD. The systemic inflammatory state (MetS) may represent a reflux-independent inflammatory pathway that increases the risk of BE. MetS did not increase risk of EA in this study population.

Age-specific risk factor profiles of adenocarcinomas of the esophagus: A pooled analysis from the international BEACON consortium

Esophageal (EA) and esophagogastric junction (EGJA) adenocarcinoma have been steadily increasing in frequency in younger people; however, the etiology of these cancers is poorly understood. We therefore investigated associations of body mass index (BMI), cigarette smoking, alcohol consumption, gastroesophageal reflux and use of nonsteroidal anti-inflammatory drugs (NSAIDs) in relation to age-specific risks of EA and EGJA. We pooled individual participant data from eight population-based, case-control studies within the international Barrett's and Esophageal Adenocarcinoma Consortium (BEACON). The analysis included 1,363 EA patients, 1,472 EGJA patients and 5,728 control participants. Multivariable logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for age-specific (<50, 50-59, 60-69, ≥70 years) cancer outcomes, as well as interactions by age. BMI, smoking status and pack-years, recurrent gastroesophageal reflux and frequency of gastroesophageal reflux were positively associated with EA and EGJA in each age group. Early-onset EA (<50 years) had stronger associations with recurrent gastroesophageal reflux (OR = 8.06, 95% CI: 4.52, 14.37; peffect modification  = 0.01) and BMI (ORBMI ≥ 30 vs . <25  = 4.19, 95% CI: 2.23, 7.87; peffect modification  = 0.04), relative to older age groups. In contrast, inverse associations of NSAID use were strongest in the oldest age group (≥70 years), although this apparent difference was not statistically significant. Age-specific associations with EGJA showed similar, but slightly weaker patterns and no statistically significant differences by age were observed. Our study provides evidence that associations between obesity and gastroesophageal reflux are stronger among earlier onset EA cancers.

Epidemiology, Diagnosis, and Management of Esophageal Adenocarcinoma

Esophageal adenocarcinoma (EAC) is rapidly increasing in incidence in Western cultures. Barrett's esophagus is the presumed precursor lesion for this cancer. Several other risk factors for this cancer have been described, including chronic heartburn, tobacco use, white race, and obesity. Despite these known associations, most patients with EAC present with symptoms of dysphagia from late-stage tumors; only a small number of patients are identified by screening and surveillance programs. Diagnostic analysis of EAC usually commences with upper endoscopy followed by cross-sectional imaging. Endoscopic ultrasonography is useful to assess the local extent of disease as well as the involvement of regional lymph nodes. T1a EAC may be treated endoscopically, and some patients with T1b disease may also benefit from endoscopic therapy. Locally advanced disease is generally managed with esophagectomy, often accompanied by neoadjuvant chemoradiotherapy or chemotherapy. The prognosis is based on tumor stage; patients with T1a tumors have an excellent prognosis, whereas few patients with advanced disease have long-term survival.

Metabolic syndrome and the risk of Barrett's oesophagus in white males

BACKGROUND

Few studies have examined the association between metabolic syndrome and Barrett's oesophagus (BO). Whether metabolic syndrome confers a risk greater than the sum of its components is unknown.

AIM

To investigate associations between metabolic syndrome, its components and BO in white males.

METHODS

We conducted a case-control study among eligible symptomatic patients scheduled for elective oesophagogastroduodenoscopy and a sample of patients eligible for screening colonoscopy recruited at primary care clinics. Metabolic syndrome was defined as the presence of at least three of: high waist-to-hip ratio (WHR), hypertriglyceridaemia, low high-density lipoprotein cholesterol, hypertension or diabetes. We used multivariate logistic regression to calculate odds ratios (OR) and 95% confidence intervals (95% CI).

RESULTS

There were 244 BO cases, 209 colonoscopy and 615 endoscopy controls. Comparing BO cases with all controls, metabolic syndrome was significantly associated with BO (OR = 1.59, 95% CI 1.05-2.40) and there was a dose effect with increasing number of metabolic syndrome components (Ptrend <0.001); when all five components were present, the OR was 2.61 (95% CI 1.14-5.99). We found that among the components, high WHR, hypertension and hypertriglyceridaemia were associated with increased risk of BO. When we compared cases with the control groups separately, metabolic syndrome was associated with BO for comparisons with endoscopy controls (OR = 1.67, 95% CI 1.10-2.55) but not colonoscopy controls (OR = 0.87, 95% CI 0.49-1.54). Associations with individual components also depended on the comparison group.

CONCLUSIONS

Metabolic syndrome is associated with an increased risk of Barrett's oesophagus in men undergoing endoscopy. Metabolic syndrome may confer additional risk of Barrett's oesophagus separate from obesity.