Determination of risk for Barrett's esophagus and esophageal adenocarcinoma

Dietary and Nutritional Support in Gastrointestinal Diseases of the Upper Gastrointestinal Tract (I): Esophagus

The esophagus is the centerpiece of the digestive system of individuals and plays an essential role in transporting swallowed nutrients to the stomach. Diseases of the esophagus can alter this mechanism either by causing anatomical damage that obstructs the lumen of the organ (e.g., peptic, or eosinophilic stricture) or by generating severe motility disorders that impair the progression of the alimentary bolus (e.g., severe dysphagia of neurological origin or achalasia). In all cases, nutrient assimilation may be compromised. In some cases (e.g., ingestion of corrosive agents), a hypercatabolic state is generated, which increases resting energy expenditure. This manuscript reviews current clinical guidelines on the dietary and nutritional management of esophageal disorders such as severe oropharyngeal dysphagia, achalasia, eosinophilic esophagitis, lesions by caustics, and gastroesophageal reflux disease and its complications (Barrett's esophagus and adenocarcinoma). The importance of nutritional support in improving outcomes is also highlighted.

Forkhead box F1 induces columnar phenotype and epithelial-to-mesenchymal transition in esophageal squamous cells to initiate Barrett's like metaplasia

Multiple genome-wide association studies (GWAS) have linked Forkhead Box F1 (FOXF1) to Barrett's esophagus (BE). Understanding whether FOXF1 is involved in initiation of Barrett's metaplasia could allow FOXF1 to be used for risk stratification and for therapy. Two-dimensional cell cultures and three-dimensional organoid cultures and well-annotated human biopsies were used to determine the role of FOXF1 in BE pathogenesis. Multiple established esophageal squamous and BE cell lines were tested in gain- and loss-of-function studies. Initiation of a BE-like metaplastic change was evaluated by measuring characteristic cytokeratins and global gene expression profiling and by culturing organoids. Epithelial-mesenchymal transition (EMT) was evaluated by immunostaining for E-cadherin, vimentin and Snail, and by cell motility assay. Columnar esophageal epithelium of BE patients exhibited higher expression of FOXF1 compared to normal squamous esophageal epithelium of GERD patients (P < 0.001). Acidic bile salts induced nuclear FOXF1 in esophageal squamous cells. FOXF1 overexpression in normal esophageal squamous cells: (a) increased columnar cytokeratins and decreased squamous cytokeratins, (b) converted squamous organoids to glandular organoids, and (c) switched global gene profiles to resemble that of human BE epithelium (P = 2.1685e - 06 for upregulated genes and P = 8.3378e - 09 for downregulated genes). FOXF1 inhibition in BE cell lines led to loss of BE differentiation markers, CK7, and mucin 2. Also, FOXF1 induced EMT and promoted cell motility in normal esophageal squamous epithelial cells. FOXF1-induced genes mapped to pathways such as Cancer, Cellular Assembly and Organization, DNA Replication, Recombination, and Repair. In conclusion, FOXF1 promotes a BE-like columnar phenotype and cell motility in esophageal squamous epithelial cells, which may have a critical role in BE development. FOXF1 should be studied further as a biomarker for BE and as a target for BE treatment.

ASMBS position statement on the rationale for performance of upper gastrointestinal endoscopy before and after metabolic and bariatric surgery

The following position statement is issued by the American Society for Metabolic and Bariatric Surgery in response to inquiries made to the Society by patients, physicians, society members, hospitals, health insurance payors, the media, and others regarding the need and possible strategies for screening endoscopic examination before metabolic and bariatric surgery (MBS), as well as the rationale, indications, and strategies for postoperative surveillance for mucosal abnormalities, including gastroesophageal reflux disease and associated esophageal mucosal injuries (erosive esophagitis and Barrett's esophagus) that may develop in the long term after MBS, specifically for patients undergoing sleeve gastrectomy or Roux-en-Y gastric bypass. The general principles described here may also apply to procedures such as biliopancreatic diversion (BPD) and BPD with duodenal switch (DS); however, the paucity of procedure-specific literature for BPD and DS limits the value of this statement to those procedures. In addition, children with obesity undergoing MBS may have unique considerations and are not specifically addressed in this position statement. This recommendation is based on current clinical knowledge, expert opinion, and published peer-reviewed scientific evidence available at this time. The statement is not intended to be and should not be construed as stating or establishing a local, regional, or national standard of care. The statement will be revised in the future as additional evidence becomes available.

In Barrett's epithelial cells, weakly acidic bile salt solutions cause oxidative DNA damage with response and repair mediated by p38

The frequency of esophageal adenocarcinoma is rising despite widespread use of proton pump inhibitors (PPIs), which heal reflux esophagitis but do not prevent reflux of weakly acidic gastric juice and bile in Barrett's esophagus patients. We aimed to determine if weakly acidic (pH 5.5) bile salt medium (WABM) causes DNA damage in Barrett's cells. Because p53 is inactivated frequently in Barrett's esophagus and p38 can assume p53 functions, we explored p38's role in DNA damage response and repair. We exposed Barrett's cells with or without p53 knockdown to WABM, and evaluated DNA damage, its response and repair, and whether these effects are p38 dependent. We also measured phospho-p38 in biopsies of Barrett's metaplasia exposed to deoxycholic acid (DCA). WABM caused phospho-H2AX increases that were blocked by a reactive oxygen species (ROS) scavenger. WABM increased phospho-p38 and reduced bromodeoxyuridine incorporation (an index of S phase entry). Repair of WABM-induced DNA damage proceeded through p38-mediated base excision repair (BER) associated with reduction-oxidation factor 1-apurinic/apyrimidinic endonuclease I (Ref-1/APE1). Cells treated with WABM supplemented with ursodeoxycholic acid (UDCA) exhibited enhanced p38-mediated responses to DNA damage. All of these effects were observed in p53-intact and p53-deficient Barrett's cells. In patients, esophageal DCA perfusion significantly increased phospho-p38 in Barrett's metaplasia. WABM exposure generates ROS, causing oxidative DNA damage in Barrett's cells, a mechanism possibly underlying the rising frequency of esophageal adenocarcinoma despite PPI usage. p38 plays a central role in oxidative DNA damage response and Ref-1/APE1-associated BER, suggesting potential chemopreventive roles for agents like UDCA that increase p38 activity in Barrett's esophagus.NEW & NOTEWORTHY We found that weakly acidic bile salt solutions, with compositions similar to the refluxed gastric juice of gastroesophageal reflux disease patients on proton pump inhibitors, cause oxidative DNA damage in Barrett's metaplasia that could contribute to the development of esophageal adenocarcinoma. We also have elucidated a critical role for p38 in Barrett's metaplasia in its response to and repair of oxidative DNA damage, suggesting a potential chemopreventive role for agents like ursodeoxycholic acid that increase p38 activity in Barrett's esophagus.

Correlation of Barrett's esophagus with colorectal polyps in Japanese patients: A retrospective chart review

BACKGROUND AND AIM

Barrett's esophagus and colorectal polyps have several overlapping risk factors. Whereas several reports in Western countries have indicated a close relationship between Barrett's esophagus and colorectal polyps, the relationship between these two diseases remains unclear in Japan. This study was performed to determine whether the prevalence of Barrett's esophagus is related to that of colorectal polyps in Japanese patients.

METHODS

The present retrospective chart review included 1582 Japanese patients who underwent both total colonoscopy and esophagogastroduodenoscopy from January 2010 to December 2016. The data on colorectal polyps and Barrett's esophagus were obtained from the endoscopic findings. The medical record of each patient was checked for age, sex, body mass index, smoking, alcohol drinking, use of acid suppression agents, and comorbidities including a history of diabetes, ischemic heart disease, gastroesophageal reflux disease, hiatal hernia, and Helicobacter pylori infection.

RESULTS

Colorectal polyps were detected in 789 of the 1582 patients (49.9%). Barrett's esophagus was detected in 233 patients (14.7%), and most cases of Barrett's esophagus (n = 229) were classified as short-segment Barrett's esophagus. Colorectal polyps were more frequent in patients with than without Barrett's esophagus (odds ratio, 1.79; 95% confidence interval, 1.31-2.46; P < 0.001). In addition to Barrett's esophagus, the data indicated that old age, male sex, obesity, smoking, alcohol drinking, diabetes mellitus, and ischemic heart disease were independent risk factors for colorectal polyps.

CONCLUSIONS

The present study revealed the correlation between the prevalence of Barrett's esophagus and colorectal polyps in Japanese patients.

Factors Associated With Recurrence of Barrett's Esophagus After Radiofrequency Ablation

BACKGROUND & AIMS

Radiofrequency ablation (RFA) is effective treatment for Barrett's esophagus (BE). However, some patients have recurrence after complete eradication of intestinal metaplasia (CEIM). We investigated the incidence of and factors associated with BE recurrence, with or without neoplasia, after RFA and CEIM using data from the national Veterans Affairs (VA) healthcare system.

METHODS

We performed a retrospective cohort study of Veterans with BE treated by RFA from 2005 through 2016 with follow-up endoscopy. Subjects were followed until BE recurrence, neoplasia, death until October 2016. CEIM, BE recurrence, and factors associated with recurrence were identified by review of medical records. We calculated incidence rates of BE recurrence, with and without neoplasia, after CEIM and identified predictors using Cox proportional hazards models.

RESULTS

We identified 430 Veterans with BE who were treated with RFA; of these 337 achieved CEIM (78.4%). Most were men (98.6%), White (83.7%), and 66.0% had baseline dysplasia. Of those with CEIM, 98 patients (29.1%) had recurrence of BE during a total 906.0 patient-years of follow-up (median 1.9 years) after CEIM (incidence, 10.8%/patient-year). Dysplasia developed in 20 patients (2.2%/patient-year) and cancer in 3 patients (0.3%/patient-year). Baseline dysplasia (hazard ratio [HR], 1.71; 95% CI, 1.03-2.84) and long-segment BE (HR, 1.59; 95% CI, 1.01-2.51) increased risk of BE recurrence whereas treatment at high-volume RFA facilities reduced risk of BE recurrence (for quartile 4 vs quartile 1: HR, 0.19; 95% CI, 0.05-0.68).

CONCLUSIONS

In a nationwide VA system study of outcomes of RFA for BE, we associated baseline dysplasia, long-segment BE, and treatment at low-volume RFA centers with recurrence of BE after CEIM. The findings call for performing these procedures in high-volume centers.

Achalasia and esophageal cancer: risks and links

Esophageal cancer affects more than 4,50,000 persons worldwide, and its incidence has increased in recent years. It is the eighth most common cancer across the globe. The main histologic types are esophageal squamous cell carcinoma (ESCC) and esophageal adenocarcinoma (EA), and their associated risk factors are well known. Achalasia, an idiopathic esophageal disorder that conditions aperistalsis and the absence of lower esophageal sphincter relaxation, stands out among them. The prevalence of ESCC in subjects with esophageal achalasia is 26 in every 1,000 cases, whereas the prevalence of EA is 4 in every 1,000. Patients with achalasia have a 50 times higher risk of presenting with ESCC than the general population, and the disease manifests 20-25 years after achalasia symptom onset. Multiple mechanisms are related to the development of ESCC in achalasia, and they include bacterial overgrowth, food stasis, genetic alterations, and chronic inflammation. Regarding the risk of EA in achalasia patients, most cases are associated with Barrett's esophagus, due to uncontrolled chronic acid reflux. Given that achalasia is a well-established factor for ESCC/EA, clinicians must be aware of said associations to enable the development of programs for the prevention and opportune detection of these cancers in patients with achalasia.

Underrated enemy - from nonalcoholic fatty liver disease to cancers of the gastrointestinal tract

Nonalcoholic fatty liver disease (NAFLD) is intrahepatic ectopic lipid deposition which is present despite a lack of other causes of secondary hepatic fat accumulation. It is the most common chronic liver disorder in the welldeveloped countries. NAFLD is a multidisciplinary disease that affects various systems and organs and is inextricably linked to simple obesity, metabolic syndrome, insulin resistance and overt diabetes mellitus type 2. The positive energy balance related to obesity leads to a variety of systemic changes including modified levels of insulin, insulin- like growth factor-1, adipokines, hepatokines and cytokines. It is strongly linked to carcinogenesis and new evidence proves that NAFLD is associated with higher risk of all-cause mortality and cancer-specific mortality among cancer survivors. This article focuses on the association between NAFLD and extrahepatic gastrointestinal tract cancers, aiming to shed light on the pathomechanism of changes leading to the development of tumors.

The potential role of leptin in tumor invasion and metastasis

The adipocyte-released hormone-like cytokine/adipokine leptin behaves differently in obesity compared to its functions in the normal healthy state. In obese individuals, elevated leptin levels act as a pro-inflammatory adipokine and are associated with certain types of cancers. Further, a growing body of evidence suggests that higher circulating leptin concentrations and/or elevated expression of leptin receptors (Ob-R) in tumors may be poor prognostic factors. Although the underlying pathological mechanisms of leptin's association with poor prognosis are not clear, leptin can impact the tumor microenvironment in several ways. For example, leptin is associated with a number of biological components that could lead to tumor cell invasion and distant metastasis. This includes interactions with carcinoma-associated fibroblasts, tumor promoting effects of infiltrating macrophages, activation of matrix metalloproteinases, transforming growth factor-β signaling, etc. Recent studies also have shown that leptin plays a role in the epithelial-mesenchymal transition, an important phenomenon for cancer cell migration and/or metastasis. Furthermore, leptin's potentiating effects on insulin-like growth factor-I, epidermal growth factor receptor and HER2/neu have been reported. Regarding unfavorable prognosis, leptin has been shown to influence both adenocarcinomas and squamous cell carcinomas. Features of poor prognosis such as tumor invasion, lymph node involvement and distant metastasis have been recorded in several cancer types with higher levels of leptin and/or Ob-R. This review will describe the current scenario in a precise manner. In general, obesity indicates poor prognosis in cancer patients.

Current Endoscopic Approaches for the Treatment of Barrett Esophagus

Barrett esophagus (BE) is the only identifiable premalignant condition for esophageal adenocarcinoma (EAC), a cancer associated with a poor 5-year survival rate. The stepwise pathologic progression of BE to invasive cancer provides an opportunity to halt progression and potentially decrease incidence and ultimately the morbidity and mortality related to this lethal cancer. Endoscopic eradication therapy (EET) in patients at increased risk of progression to invasive EAC (intramucosal EAC, high-grade dysplasia, and low-grade dysplasia) is a practice that is endorsed by multiple societies and has replaced esophagectomy as the standard of care for these patients. Although the effectiveness, safety, and durability of EET have been demonstrated in several studies, this review addresses the several challenges with EET that need to be considered to optimize patient outcomes. Finally, the critical role of training, competence, and quality indicators in EET are emphasized in this era of value-based health care practice.