Morphologic features are useful in distinguishing Barrett esophagus from carditis with intestinal metaplasia

The Meaning of Incidental Goblet Cells at the Gastroesophageal Junction

BACKGROUND AND AIMS

The causes for the occurrence of goblet cells at the gastroesophageal junction (GEJ-GC) are unknown. The aim of our study was to compare the concurrent histologic changes of the stomach in (1) patients with GEJ-GC, but without Barrett's esophagus (BE) to those in (2) patients with BE and in (3) controls without GEJ-GC or BE.

METHODS

We used an electronic database of histopathologic records from 1.3 million individual patients, who underwent esophago-gastro-duodenoscopy (EGD) in 2009-2018. We compared the prevalence of Helicobacter pylori-positive gastritis (HpG), gastric intestinal metaplasia (G-IM), chronic inactive gastritis (CIG), and reactive gastropathy (RG) among the 3 patient groups, using odds ratios and their 95% confidence intervals.

RESULTS

Of all EGD patients, 4.0% harbored BE and 2.4% GEJ-GC. The average age of patients with GEJ-GC (60 ± 14) was significantly younger than the age of patients with BE (63 ± 12) and significantly older than the age of controls (55 ± 17). Female subjects were more common among GEJ-GC (54%) than BE (37%), but less common than among controls (63%). The 3 gastric histopathology changes associated with H. pylori were significantly more common in GEJ-GC than BE (for HpG 2.42, 2.29-2.56; for G-IM 1.82, 1.73-1.92; for CIG 1.31, 1.22-1.41). The corresponding differences between GEJ-GC and controls were less striking (for HpG 0.97, 0.93-1.01; for G-IM 1.15, 1.11-1.19; for CIG 0.90, 0.85-0.95). RG was slightly less common in GEJ-GC than BE (0.89, 0.86-0.92) and controls (0.94, 0.91-0.96).

CONCLUSIONS

With respect to its demographic and histopathologic features, GEJ-GC likely represents gastric intestinal metaplasia as opposed to BE and should prompt gastric intestinal metaplasia screening and management.

The indications for biopsy in routine upper gastrointestinal endoscopy

This review describes the indications and contraindications for endoscopic biopsy, in routine practice, of the upper gastrointestinal (GI) tract. We accept that this review provides grounds for controversy, as our stance in certain situations is counter to some national guidelines. Nevertheless, we provide evidence to support our viewpoints, especially on efficiency and economic grounds. We describe the particular controversies concerning the biopsy assessment of Barrett's oesophagus, chronic gastritis and the duodenum in the investigation of coeliac disease. We accept that there are indications for more extensive upper GI biopsy protocols in children than in adults; the latter constitute our main focus in this article. We would encourage detailed discussion between pathologists and their endoscopy colleagues about the indications, or lack of them, for routine upper GI endoscopic biopsy, as studies have shown that adherence to agreed guidelines has resulted in a very considerable diminution in the biopsy workload without compromising patient management. Furthermore, where biopsy is indicated, we emphasise the importance of accompanying clinical information provided to the pathologist, in particular regarding biopsy site(s), and regular feedback to endoscopists to improve and maintain the quality of such information. Finally, local dialogue is also advised, when necessary, to indicate to endoscopists the need to appropriately segregate biopsies into separate, individually labelled specimens, to maximise the information that can be derived by pathological evaluation and thereby improve the quality of the final pathology report.

Unraveling the identity of gastric cardiac cancer

The classification of gastric cardiac carcinoma (GCC) is controversial. It is currently grouped with esophageal adenocarcinoma (EAC) as an adenocarcinoma of the gastroesophageal junction (GEJ). Recently, diagnostic criteria for adenocarcinoma in the GEJ were established and GCC was separated from EAC. We viewed published evidence to clarify the GCC entity for better patient management. GCC arises in the cardiac mucosa located from 3 cm below and 2 cm above the GEJ line. Compared with EAC, GCC is more like gastric cancer and affects a higher proportion of female patients, younger patients, those with a lower propensity for reflux disease, a wider histopathologic spectrum, and more complex genomic profiles. Although GCC pathogenesis mechanisms remain unknown, the two-etiology proposal is appealing: in high-risk regions, the Correa pathway with Helicobacter pylori infection, chronic inflammation, low acid and intestinal metaplasia, dysplasia and carcinoma may apply, while in low-risk regions the sequence from reflux toxin-induced mucosal injury and high acid, to intestinal metaplasia, dysplasia and carcinoma may occur. In early GCC a minimal risk of nodal metastasis argues for a role of endoscopic therapy, whereas in advanced GCC, gastric cancer staging rules and treatment strategy appear to be more appropriate than the esophageal cancer staging scheme and therapy for better prognosis stratification and treatment. In this brief review we share recent insights into the epidemiology, histopathology and genetics of GCC and hope that this will stimulate further investigations in order to improve the clinical management of patients with GCC.

Interaction Between Ethnicity and Helicobacter pylori Infection in the Occurrence of Reflux Disease

BACKGROUND AND AIMS

Few reports are available to reliably assess the ethnic distribution of Barrett metaplasia and reflux esophagitis. The present study served to analyze the joint influence of Helicobacter pylori infection and patient demographics on the diagnoses of Barrett metaplasia and reflux esophagitis.

METHODS

The Inform Diagnostics database is a national electronic repository of histopathologic records of patients distributed throughout the United States. In a case-control study of 52,096 cases with Barrett metaplasia, 189,235 cases with reflux esophagitis, and 152,322 controls without any signs or symptoms suggestive of gastroesophageal reflux disease, we assessed the influence of age, gender, ethnicity, and H. pylori status on occurrence of Barrett metaplasia or reflux esophagitis.

RESULTS

Barrett metaplasia was less common among East Asians (with odds ratio, 0.48; 95% confidence interval, 0.44-0.53) and Hispanics (0.60, 0.57-0.63) than other ethnic groups living in the United States. Reflux esophagitis was also less common among East Asians (0.86, 0.82-0.90), but more common among Hispanics (1.18, 1.14-1.21). Both types of esophageal disease were associated with a lower prevalence rates of gastric H. pylori infection than controls, with 0.48, 0.44-0.53 for Barrett metaplasia and 0.60, 0.57-0.63 for reflux esophagitis. The prevalence rates of gastric H. pylori and both esophageal diseases were greater in older than younger and male than female patients in all ethnic groups alike.

CONCLUSIONS

Gastric H. pylori infection, ethnicity, gender, and age all influence the occurrence of Barrett metaplasia, and reflux esophagitis.

Upper Gastrointestinal Disease Influences the Occurrence of Inflammatory Bowel Disease

BACKGROUND AND AIMS

Compromise of the gastric acid barrier may facilitate bacterial invasion of the lower intestinal tract and influence the occurrence of inflammatory bowel disease (IBD). Our study tested the associations between histopathologic changes in the upper and lower gastrointestinal tract in patients undergoing bidirectional endoscopy.

METHODS

The Inform Diagnostics database is a national electronic repository of histopathologic records of patients distributed throughout the entire USA. A case-control study among 302,061 patients, of whom 13,943 harbored IBD, evaluated whether the occurrence of Crohn's disease or ulcerative colitis was influenced by the presence of various upper gastrointestinal diagnoses associated with lowered gastric acid output. The influence of individual risk factors on the occurrence of colonic disease was expressed as odds ratios with their 95% confidence intervals.

RESULTS

The odds ratio for Crohn's disease being associated with gastric H. pylori was 0.30 (0.24-0.37), with intestinal metaplasia 0.30 (0.24-0.39), with fundic gland polyps 0.42 (0.35-0.50), with gastric hyperplastic polyps 0.35 (0.23-0.51), with Barrett's metaplasia 0.19 (0.14-0.24), and with reflux esophagitis 0.46 (0.42-0.51). The odds ratio for ulcerative colitis being associated with gastric H. pylori was 0.58 (0.50-0.67), with intestinal metaplasia 0.39 (0.32-0.47), with fundic gland polyps 0.61 (0.53-0.71), with gastric hyperplastic polyps 0.64 (0.49-0.84), with Barrett's metaplasia 0.50 (0.43-0.59), and with reflux esophagitis 0.77 (0.71-0.84).

CONCLUSIONS

A diminished gastric acid barrier function, as evidenced by various upper gastrointestinal diseases associated with lowered gastric acid output, may exert a protective influence against the development of inflammatory bowel disease.

Decreased risk for microscopic colitis and inflammatory bowel disease among patients with reflux disease

AIM

Previous studies have found an increased risk for microscopic colitis (MC) associated with proton pump inhibitors. In patients with ulcerative colitis (UC) or Crohn's disease (CD), proton pump inhibitors have been associated with an increased risk for IBD flares and impaired outcomes. The aim of this study was to test the epidemiological associations between gastro-oesophageal reflux disease (GERD) and MC, UC or CD in a large database.

METHOD

The Miraca Life Sciences Database is a national electronic repository of histopathological records of patients distributed throughout the entire USA. A case-control study evaluated whether the presence of Barrett's metaplasia, erosive oesophagitis on endoscopy or histological signs of reflux oesophagitis, clinical diagnosis of GERD or any GERD type affected the occurrence of MC, UC or CD among 228 506 subjects undergoing bidirectional endoscopy. Multivariate logistic regression analyses were used to calculate ORs and their 95% CI for the risk of MC, UC or CD associated with various types of GERD and were adjusted for age, sex and presence of Helicobacter pylori.

RESULTS

The analysis revealed an inverse relationship between GERD and different types of inflammatory bowel disease. The inverse relationships applied similarly to MC (mean = 0.62, 95% CI: 0.58-0.66), UC (mean = 0.89, 95% CI: 0.81-0.97) and CD (mean = 0.76, 95% CI: 0.69-0.85). It also applied to different forms of GERD, with a trend towards more pronounced inverse relationships associated with Barrett's metaplasia or erosive oesophagitis than clinical diagnosis of GERD.

CONCLUSION

Gastro-oesophageal reflux disease is inversely associated with all forms of inflammatory bowel disease, such as MC, UC, or CD.

Histology of Barrett's Metaplasia: Do Goblet Cells Matter?

This review has provided a summary of the biology of goblet cell metaplasia in CLE as it pertains to BE. Goblet cells are terminally differentiated nonproliferative cells that have many overlapping histochemical characteristics with mucinous columnar cells and pseudogoblet cells. There is an abundance of evidence that suggests that use of goblet cells as a biomarker of BE, and its progression to malignancy, is problematic. Some of these limitations include the fact that the background non-goblet epithelium in most patients with CLE is biologically intestinalized and contains molecular abnormalities similar to goblet cell CLE, goblet cells fluctuate with time and decrease in number with progression of neoplasia, and pathologists have problems with interpretation, and distinction, of goblet cells from other types of cells in the esophagus. Sampling error results in sensitivity and specificity issues that limit its positive predictive value. Goblet cells are fewest in number in the same population of patients with CLE that are hardest to detect endoscopically (i.e., those with short or ultrashort CLE). Nevertheless, the risk of cancer in patients with short-segment BE, a condition difficult to distinguish from the stomach, is very low regardless of the presence or absence of goblet cells so it is unclear what the role of goblet cells is in these patients as a biomarker. Nevertheless, if the answer to the following question, "Would you as a gastroenterologist recommend surveillance for a patient with clear endoscopic evidence of CLE, particularly if it is ≥ 3 cm in length, but in which goblet cells were not reported to be present by the pathologist," is yes, then the US requirement for goblet cells as part of the criteria for "BE" is superfluous.

Increased Risk for Colon Polyps in Patients with Reflux Disease

BACKGROUND

Previous studies have found an increased risk for colonic neoplasm in patients with Barrett's esophagus. It is unknown whether such risk applies similarly to other types of gastroesophageal reflux disease (GERD).

AIMS

To test whether GERD represents a risk factor for the occurrence of colon polyps.

METHODS

The Miraca Life Sciences Database is a large national electronic repository of histopathologic records of patients distributed throughout the entire USA. A case-control study evaluated whether presence of (1) Barrett's metaplasia, (2) erosive esophagitis on endoscopy or histologic signs of reflux esophagitis, (3) clinical diagnosis of GERD, (4) any type of GERD affected the occurrence hyperplastic polyps (HP), sessile serrated adenomas/polyps (SSA/P), or tubular adenomas (TA) among 228,506 subjects undergoing bidirectional endoscopy. Multivariate logistic regression analyses were used to calculate odds ratios and their 95% confidence intervals for the risk of HP, TA or SSA/P associated with various types of GERD and adjusted for age, sex, and presence of H. pylori.

RESULTS

The analysis revealed positive associations between GERD and all types of colon polyps. These associations applied similarly to HP (1.47, 1.44-1.50), TA (1.30, 1.27-1.32), and SSA/P (1.52, 1.46-1.58). They also applied to different forms of GERD, showing a trend toward stronger associations, that is higher odds ratios, with Barrett's metaplasia or erosive esophagitis than clinical diagnosis of GERD.

CONCLUSION

All types of GERD represent a risk factor for the occurrence of different colon polyps, such as HP, TA, or SSA/P.

Histologic Features Associated With Columnar-lined Esophagus in Distal Esophageal and Gastroesophageal Junction (GEJ) Biopsies From GERD Patients: A Community-based Population Study

There are inherent problems with the endoscopic and pathologic criteria for columnar-lined esophagus (CLE). Furthermore, the clinical and biological significance of an irregular squamocolumnar junction (SCJ) is unclear. The aim of this study was to evaluate the association between histologic features in SCJ biopsies and CLE and to gain insight into the significance of an irregular SCJ. The study was a cross-sectional analysis of 2176 mucosal biopsies of the SCJ from 544 patients in a large prospective community clinic-based study of gastroesophageal reflux disease in Washington State. Biopsy samples were evaluated blindly for a wide variety of histologic features, such as the presence and type of mucosal glands, submucosal glands and ducts, goblet cells, multilayered epithelium (ME), inflammation, and buried columnar epithelium. Histologic findings were correlated with the endoscopic findings (normal Z-line, irregular Z-line, or CLE) and evaluated by logistic regression and receiver operating characteristic analysis.Five histologic features were associated with CLE: pure mucous glands, ME, presence of goblet cells, ≥50% of crypts with goblet cells, and buried columnar epithelium. Pure oxyntic glands were inversely associated with CLE. The features most strongly related to CLE included biopsies with ≥50% of crypts with goblet cells, ME, and mucosal gland type (area under the curve=0.71; 95% confidence interval=0.66-0.76). Patients with an irregular Z-line were histologically similar to those with CLE. Certain histologic features in biopsies of the SCJ are associated with the presence of CLE. Irregularity of the Z-line is probably indicative of ultrashort segment CLE, instead of being a potential variation of normal.

Pathology of esophageal cancer and Barrett's esophagus

Esophageal cancer is a serious malignancy with high mortality. The two common distinctive pathologic subtypes of esophageal cancer are squamous cell carcinoma and adenocarcinoma. These differ with regards to etiology, ethnic distribution, pathogenesis, and location in the esophagus. The precursor lesions are also unique to each subtype. Squamous cell carcinoma is more common in East Asia, is linked to smoking and tobacco use, more commonly involves the middle esophagus, and the precursor lesion is squamous dysplasia. Adenocarcinoma is more common in the United States and certain European countries, associated with obesity and gastroesophageal reflux disease (GERD), more commonly involves the distal esophagus, and the precursor lesion is Barrett's esophagus. Endoscopic surveillance with biopsy evaluation is the standard of care in high-risk groups. Endoscopic ablative therapies for early cancers have lower morbidity than surgery. Despite increased awareness, identification of high-risk groups and endoscopic surveillance, a large proportion of patients present with advanced cancers. Surgery and chemoradiation, either in neo-adjuvant or adjuvant setting, is the usual treatment for patients with advanced but resectable esophageal cancers. The prognosis and further management largely depends upon the pathologic tumor-node-metastasis (TNM) staging provided by the American Joint Committee on Cancer (AJCC) and the International Union against Cancer. Currently, the 7th edition of TNM staging system is being applied for prognostication and this is more focused on pathologic evaluation. Eighth edition of AJCC/UICC TNM staging has been introduced and will be implemented for clinical use in 2018.

The influence of Helicobacter pylori on the ethnic distribution of Barrett's metaplasia

BACKGROUND

Environmental risk factors associated with ethnicity may contribute to the occurrence of Barrett's metaplasia.

AIM

To investigate the interaction between ethnicity and Helicobacter pylori infection in the occurrence of Barrett's metaplasia among patients undergoing oesophago-gastro-duodenoscopy.

METHODS

The Miraca Life Sciences Database is an electronic repository of histopathological patient records. A case-control study evaluated the influence of age, gender, ethnicity and histological diagnosis of H. pylori on the occurrence of Barrett's metaplasia.

RESULTS

The total study population comprised 596 479 subjects, of whom 76 475 harboured a diagnosis of Barrett's metaplasia. Male sex, age and H. pylori infection in declining order exerted the strongest influence on the occurrence of BM. In comparison with the population comprising Caucasians and African Americans, Barrett's metaplasia was less common among subjects of African (OR = 0.09, 95% CI = 0.01-0.43), Middle Eastern (0.26, 0.20-0.34), East Asian (0.35, 0.31-0.40), Indian (0.39, 0.32-0.47), Hispanic (0.62, 0.59-0.64) or Jewish descent (0.50, 0.45-0.54), but more common among subjects of Northern European descent (1.14, 1.03-1.26). With the exception of Jews and Northern Europeans, all other ethnic subgroups were characterised by a higher prevalence of H. pylori than the comparison group. A low prevalence of H. pylori was significantly associated with a high prevalence of Barrett's metaplasia (R² = 0.82, P < 0.001), as well as dysplasia or oesophageal adenocarcinoma (R² = 0.81, P < 0.001).

CONCLUSION

Our analysis reveals an inverse relationship between the prevalence of Barrett's metaplasia and H. pylori gastritis among different ethnic groups within the United States.

Barrett's Esophagus: A Comprehensive and Contemporary Review for Pathologists

This review provides a summary of our current understanding of, and the controversies surrounding, the diagnosis, pathogenesis, histopathology, and molecular biology of Barrett's esophagus (BE) and associated neoplasia. BE is defined as columnar metaplasia of the esophagus. There is worldwide controversy regarding the diagnostic criteria of BE, mainly with regard to the requirement to histologically identify goblet cells in biopsies. Patients with BE are at increased risk for adenocarcinoma, which develops in a metaplasia-dysplasia-carcinoma sequence. Surveillance of patients with BE relies heavily on the presence and grade of dysplasia. However, there are significant pathologic limitations and diagnostic variability in evaluating dysplasia, particularly with regard to the more recently recognized unconventional variants. Identification of non-morphology-based biomarkers may help risk stratification of BE patients, and this is a subject of ongoing research. Because of recent achievements in endoscopic therapy, there has been a major shift in the treatment of BE patients with dysplasia or intramucosal cancer away from esophagectomy and toward endoscopic mucosal resection and ablation. The pathologic issues related to treatment and its complications are also discussed in this review article.

Recent advances in proximal gastric carcinoma

The American Joint Committee on Cancer (AJCC) staging scheme requires staging proximal gastric carcinoma (PGC) as esophageal adenocarcinoma (EAC), which has been shown to be controversial by recent research results. To update the current research findings on PGC, we systematically reviewed and analyzed the scientific evidence on key arguments related to PGC. The data of high-quality research articles showed that PGC arised in the cardiac mucosa in the proximal stomach within 3 cm below the gastroesophageal junction. Its incidence is rising in East Asian countries, but decreasing in the West, and plateaued at a low level in the United States. PGC is a slowly progressive cancer with unknown independent risk factors and the mechanisms of pathogenesis. This carcinoma exhibits a wide histopathological spectrum and heterogeneous post-resection patient survival characteristics, and cannot be adequately staged for prognotic stratification by the current AJCC staging classification. The results on PGC genomics reveal unique genetic profiles, especially in East Asian populations. In conclusion, mounting evidence defies a simple placement of PGC in a single category of EAC for disease classification; further investigations on the mechanisms of PGC pathogenesis are urgently needed.

The changing role of the pathologist in the management of Barrett's oesophagus

Pathological specimens from columnar-lined oesophagus (CLO) comprise a considerable proportion of the workload of gastrointestinal pathologists in Western countries. There remain controversies concerning the diagnostic role of pathology. More recently, in the UK at least, the diagnosis has been regarded as primarily an endoscopic endeavour, with pathology being corroborative and only diagnostic when endoscopic features are equivocal or when there are additional features that make the endoscopic diagnosis unclear. There is also recognition that demonstration of intestinalisation or 'goblet cells' is not paramount, and should not be required for the diagnosis. There have been notable changes in the management of CLO neoplasia: pathologists are centrally involved in its management. Pathological assessment of endoscopic mucosal resection (EMR) specimens provides the most useful means of determining the management of early neoplasia and of determining indications for surgery. This represents an extraordinarily rapid change in management, in that, <10 years ago, laborious Seattle-type biopsy protocols were recommended, and high grade dysplasia was an indication for resectional surgery. Now, individual patient management is paramount: multi-professional meetings determine management after biopsy and EMR assessment. One significant change is that major resections are undertaken less often, in Western countries, for CLO neoplasia.

Significance of paneth cell metaplasia in Barrett esophagus: a morphologic and clinicopathologic study

OBJECTIVES

The metaplastic intestinal epithelium in Barrett esophagus (BE) occasionally contains Paneth cells; however, little is known regarding the prevalence and significance of Paneth cell metaplasia (PCM) in BE.

METHODS

We evaluated 757 esophageal biopsy specimens with intestinal metaplasia (IM) for PCM. Outcome analysis was performed in 299 cases with complete clinical data using multinomial logistic regression.

RESULTS

Thirty-one percent (234/757) of the IM cases showed PCM. Paneth cells are decreased when BE epithelium becomes increasingly dysplastic. Long-segment BE shows significantly more PCM than short-segment BE. On follow-up biopsies, patients without PCM (NPCM) are three times more likely to regress than patients with PCM, regardless of dysplasia, BE segment length, age, or sex. However, there is no significant difference in terms of progression to dysplasia/adenocarcinoma between the PCM and NPCM groups.

CONCLUSIONS

The presence of PCM is associated with less disease regression and is not associated with more disease progression.

Barrett's oesophagus diagnostic criteria: endoscopy and histology

This review summarizes the endoscopic and histologic features of Barrett's oesophagus(BO) as well as some of the recent advancements and controversies. BO represents metaplastic conversion of normal squamous epithelium of tubular oesophagus to columnar epithelium. The diagnosis of BO requires a combination of endoscopic and histopathologic findings. There is worldwide controversy regarding the exact definition of BO, particularly with regard to the requirement to histologically identify goblet cells in biopsies. The presence and detectability of goblet cells might vary depending on a variety of factors and is subject to sampling error. Therefore, a systematic biopsy sampling with sufficient number of biopsies is currently recommended to limit the likelihood of a false negative result for detection of goblet cells. There are both endoscopic and pathologic challenges in evaluating gastro-oesophageal junction biopsies in patients with irregular Z lines to determine the exact location of the sample (i.e., oesophagus versus stomach). Recently, several novel endoscopic techniques have been developed to improve BO detection. However, none have been validated yet in clinical practice. The surveillance of patients with BO relies on histologic evaluation of dysplasia. However, there are significant pathologic limitations and diagnostic variability in evaluating the presence and grading of BO dysplasia, particularly with regard to the more recently recognized non-intestinal types of dysplasia. All BO dysplasia samples should be reviewed by an expert gastrointestinal pathologist to confirm the diagnosis. Finally, it is important to emphasize that close interaction between gastroenterologists and pathologists is essential to ensure proper evaluation of endoscopic biopsies in order to optimize the surveillance and clinical management of patients with BO.

Current issues in Barrett's esophagus and Barrett's-related dysplasia

Surgical pathologists frequently encounter biopsies in patients with Barrett's esophagus (BE), defined as replacement of the normal stratified squamous epithelium of the distal esophagus by metaplastic columnar epithelium containing goblet cells. Thus, one of the primary roles of the pathologist is to definitively identify goblet cells, best done on routine stained sections. It has recently been questioned as to whether goblet cells should be absolutely necessary to render a diagnosis of BE, given immunohistochemical and flow cytometric similarities between columnar-lined esophagus with and without goblet cells. Once a diagnosis of BE is rendered, the pathologist must state, using a simple classification, whether the biopsy is negative for dysplasia or shows dysplasia (low-grade dysplasia or high-grade dysplasia). However, there are a number of known pitfalls in distinguishing dysplasia from reactive epithelium, and it can be similarly difficult to distinguish low-grade dysplasia from high-grade dysplasia. In addition, there are some cases in which the distinction of high-grade dysplasia from intramucosal adenocarcinoma can be challenging. All of these issues are summarized in this paper.

Changing trends in the proportions of small (≤ 2 cm) proximal and non-proximal gastric carcinomas treated at a high-volume tertiary medical center in China

OBJECTIVE

Guided by the recently established histological criteria of the gastroesophageal junction (GEJ), we aimed to investigate and compare trends in the proportions of small (≤ 2 cm) proximal gastric carcinoma (PGC) vs non-PGC (NPGC) in Chinese patients over an 8-year period.

METHODS

The study was conducted with consecutive surgical resected specimens of small PGC that was located within 3 cm below the GEJ and NPGC (located at all other gastric regions) treated at a single medical center in China. Differences in proportions between the two groups were compared.

RESULTS

Among all 313 cases, 111 (35.5%) were classified as PGC and the remaining 202 (64.5%) as NPGC. Patients with PGC were significantly elder than those with NPGC, and none aged younger than 40 years. The proportions of PGC significantly and progressively increased from 16% in 2004 to 45% in 2011, in contrast to a steady decreasing trend for NPGC from 84% to 55% over the same period. The difference in trends between the two groups approached, but was not at a statistically significant level (P = 0.08). Proportions of small cancers in the gastric corpus and in female patients remained low and stable, in contrast to a significantly higher proportion in male patients (P < 0.05).

CONCLUSIONS

Our data showed a significantly upward-shifting trend in the proportions of small PGC, primarily in elderly male patients, in contrast to a downward shifting trend in NPGC over the most recent 8-year period in Chinese patients.

A pSMAD/CDX2 complex is essential for the intestinalization of epithelial metaplasia

The molecular mechanisms leading to epithelial metaplasias are poorly understood. Barrett's esophagus is a premalignant metaplastic change of the esophageal epithelium into columnar epithelium, occurring in patients suffering from gastroesophageal reflux disease. Mechanisms behind the development of the intestinal subtype, which is associated with the highest cancer risk, are unclear. In humans, it has been suggested that a nonspecialized columnar metaplasia precedes the development of intestinal metaplasia. Here, we propose that a complex made up of at least two factors needs to be activated simultaneously to drive the expression of intestinal type of genes. Using unique animal models and robust in vitro assays, we show that the nonspecialized columnar metaplasia is a precursor of intestinal metaplasia and that pSMAD/CDX2 interaction is essential for the switch toward an intestinal phenotype.

Barrett esophagus: diagnostic challenges

The incidence of esophageal adenocarcinoma and associated mortality has risen dramatically over the past several decades, and, thus, it is increasingly important to understand its pathogenesis and risk factors. Barrett esophagus is the established precursor to esophageal adenocarcinoma that progresses through a metaplasia-dysplasia-carcinoma sequence. Its risk of transforming to carcinoma is not as high as previously reported and there appears to be a biological heterogeneity among patients with this disease. The overall prevalence of Barrett esophagus in the United States ranges from 1% to 25% and is closer to 5% in patients with gastroesophageal reflux disease. Because of the frequency of Barrett esophagus and associated implications, it is important for the practicing pathologist to have a thorough understanding of this disease and its diagnostic pitfalls. In this review, we will discuss issues associated with the diagnosis of Barrett esophagus, including the definition of Barrett esophagus and its distinction from carditis with intestinal metaplasia. We will also discuss challenges in the grading of dysplasia and new variants of dysplasia, including crypt dysplasia and foveolar-type dysplasia. Finally, we will touch upon the evaluation of dysplasia in endoscopic mucosal resection specimens.

Histopathology in barrett esophagus and barrett esophagus-related dysplasia

Pathologic specimens, both biopsies and endoscopic mucosal resections, for Barrett esophagus and Barrett-associated dysplasia and malignancy are common for pathologists in North America, and the incidence in South Asian countries seems to be increasing. Dysplasia and malignancy arising in intestinalized gastric-type mucosa raises issues in the interpretation of dysplasia and the evaluation of the depth of invasion of malignancies that are not seen in squamous dysplasia and squamous cell carcinoma. We review the North American approach to these lesions.

British Society of Gastroenterology guidelines on the diagnosis and management of Barrett's oesophagus

These guidelines provide a practical and evidence-based resource for the management of patients with Barrett's oesophagus and related early neoplasia. The Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument was followed to provide a methodological strategy for the guideline development. A systematic review of the literature was performed for English language articles published up until December 2012 in order to address controversial issues in Barrett's oesophagus including definition, screening and diagnosis, surveillance, pathological grading for dysplasia, management of dysplasia, and early cancer including training requirements. The rigour and quality of the studies was evaluated using the SIGN checklist system. Recommendations on each topic were scored by each author using a five-tier system (A+, strong agreement, to D+, strongly disagree). Statements that failed to reach substantial agreement among authors, defined as >80% agreement (A or A+), were revisited and modified until substantial agreement (>80%) was reached. In formulating these guidelines, we took into consideration benefits and risks for the population and national health system, as well as patient perspectives. For the first time, we have suggested stratification of patients according to their estimated cancer risk based on clinical and histopathological criteria. In order to improve communication between clinicians, we recommend the use of minimum datasets for reporting endoscopic and pathological findings. We advocate endoscopic therapy for high-grade dysplasia and early cancer, which should be performed in high-volume centres. We hope that these guidelines will standardise and improve management for patients with Barrett's oesophagus and related neoplasia.

Presence or absence of intestinal metaplasia but not its burden is associated with prevalent high-grade dysplasia and cancer in Barrett's esophagus

Universal agreement on the inclusion of intestinal metaplasia to diagnose Barrett's esophagus (BE) is lacking. Our aim was to determine the association of intestinal metaplasia and its density with the prevalence of dysplasia/cancer in columnar lined esophagus (CLE). Patients with CLE but no intestinal metaplasia (CLE-no IM) were identified by querying the clinical pathology database using SNOMED codes for distal esophageal biopsies. CLE-IM patients were identified from a prospectively maintained database of BE patients. Subsequently, relative risks for prevalent dysplasia and cancer were calculated. Since patients with CLE-no IM are not usually enrolled in surveillance, only prevalent dysplasia/cancer on index endoscopy was analyzed. Goblet cell density and percent intestinal metaplasia were estimated. All biopsy slides were reviewed for dysplasia by two experienced gastrointestinal pathologists. Two hundred sixty-two CLE-IM and 260 CLE-no IM patients were included (age 64±12 vs. 60±11 years, P=0.001; whites 92% vs. 82%, P=0.001; males 99.7% vs. 99.3%, P=NS; CLE length 3.4±3.2 vears 1.4±0.4 cm, P=0.001 and hiatus hernia 64% vs. 56%, P=0.013). The odds of finding low-grade dysplasia and of high-grade dysplasia (HGD)/cancer were 12.5-fold (2.9-53.8, P=0.007) and 4.2-fold (95% CI 1.4-13, P=0.01) higher, respectively, in the CLE-IM group. Reanalysis after controlling for important variables of age, race, and length did not significantly alter the overall results. In CLE-IM group, when patients with high (>50/LPF) versus low goblet cell density (<50/LPF) and <10% versus >10% intestinal metaplasia were compared, the odds of HGD/cancer, OR 1.5 (0.5-4.9, P=0.5) and 1.97 (0.54-7.22), respectively, were not significantly higher. Demonstration of intestinal metaplasia continues to be an essential element in the definition of BE, but its quantification may not be useful for risk stratification of HGD/cancer in BE.

Barrett Esophagus: Evolving Concepts in Diagnosis and Neoplastic Progression

Surgical pathologists need to answer 2 questions when evaluating biopsies from the distal esophagus or gastroesophageal junction in patients with a history of gastroesophageal reflux disease: Are the findings consistent with Barrett esophagus? and Is there any evidence of dysplasia? Pathologists should be well informed about the controversy around the definition of Barrett esophagus and the common pitfalls that lead to a false-positive diagnosis of Barrett esophagus or Barrett esophagus-associated dysplasia. A concise description of distinct morphologic types of dysplasia in Barrett esophagus and a summary of recent data on the natural history of BE are provided in this review.

Barrett's metaplasia and colonic neoplasms: a significant association in a 203,534-patient study

BACKGROUND AND AIM

The presence of an association between Barrett's metaplasia and colonic neoplasia has remained controversial. The aim of the study was to test the presence of this association, using a large national database.

METHODS

From a computerized database of surgical pathology reports, we selected 203,000 subjects who underwent colonoscopy and esophago-gastro-duodenoscopy with biopsy results available from both procedures. In a case-control study we compared the occurrence of Barrett's metaplasia in patients with and without various types of colonic neoplasms.

RESULTS

Barrett's metaplasia occurred more frequently among patients with hyperplastic polyps (OR = 2.14, 95 % CI 2.02-2.27), adenomatous polyps (2.52, 2.41-2.64), advanced adenomas (2.10, 1.90-2.32), villous adenomas or adenomas with high-grade (HG) dysplasia (2.45, 2.28-2.64), and colonic adenocarcinomas (1.75, 1.39-2.22). The association between Barrett's metaplasia and colonic neoplasm applied similarly to polyps of different size, number and location within the large bowel. These types of association could also be confirmed when analyzed separately for Barrett's metaplasia characterized by low-grade or HG dysplasia, as well as esophageal adenocarcinoma.

CONCLUSIONS

The data support the existence of a true association between Barrett's metaplasia and various types of colonic neoplasm. The association may be more interesting for its potential insights into the pathogenesis of the two disorders than its actual clinical implications.

Columnar-lined esophagus in Chinese patients with proximal gastric carcinomas

OBJECTIVE

To investigate the clinicopathological features of columnar-lined esophagus (CLE) in Chinese patients.

METHODS

Among 182 consecutive resections of proximal gastric cancer with residual esophageal tissue, 114 were eligible for the study. The maximal lengths of CLE and superficial esophageal glands (SEG) and the presence or absence of chronic inflammation (CI), lymphoid follicles (LF), Helicobacter pylori (H. pylori) infection, intestinal metaplasia (IM), pancreatic metaplasia (PM) and dysplasia were analyzed and compared with those in the adjacent proximal gastric mucosa.

RESULTS

SEG were present in 110 cases with a mean length of 5.4 mm (range 1-16 mm, 90% equal to or under 10 mm and 10% between 11-16 mm). These glands were associated with CI (95%), LF (85%), H. pylori infection (42%), IM (25%), PM (36%) and dysplasia (10%). CLE was found in 65% of the cases and was associated with SEG (mean length of 4.0 mm, range 1-13 mm, 97% within 10 mm and 3% between 11-13 mm). The frequencies of CI (97%), LF (86%), H. pylori infection (65%) and PM (46%) in CLE were similar to those in the proximal stomach (CI 90%, LF 54%, H. pylori infection 58%, PM 39%). In contrast, the frequencies of IM (37%) and dysplasia (15%) in CLE were significantly lower than those in the proximal stomach (66% and 31%, respectively; P < 0.01).

CONCLUSIONS

CLE in Chinese patients was within 10 mm in length in 97% of cases, and with SEG and H. pylori infection-related changes similar to those in the proximal stomach.

Inverse association of esophageal eosinophilia and Barrett esophagus

BACKGROUND

The high frequency of gastroesophageal reflux symptoms reported in patients with eosinophilic esophagitis has suggested that the two disorders may be associated; however, few studies have systematically addressed this issue.

GOALS

To determine the frequency of the simultaneous occurrence of esophageal eosinophilia and Barrett esophagus and define the clinical characteristics of patients with both conditions.

STUDY

From a national pathology database of patients who had esophagogastroduodenoscopy with mucosal biopsies we extracted patients with a diagnosis of Barrett mucosa, eosinophilic esophagitis pattern of injury [(≥15 eosinophils/high-power field (HPF)], or both. We then evaluated their respective clinicopathologic associations.

RESULTS

Among 233,662 unique patients evaluated during the study period, Barrett mucosa without increased eosinophils was diagnosed in 29,733 patients (12.7%; median age 63 y; 67.6% male); eosinophil counts of ≥15/HPF were recorded in 9509 patients without Barrett mucosa (4.1%; median age 44 y; 63.9% male). A simultaneous diagnosis of Barrett mucosa and ≥15 eosinophils/HPF in the squamous epithelium and was made in 404 unique patients (0.17%; median age 56 y; 79.5% male). The observed prevalence of the simultaneous occurrence of the two conditions was one third of that expected if they occurred independently (odds ratio 0.29; 95% confidence interval, 0.27-0.33; P<0.0001).

CONCLUSIONS

These data suggest a strong inverse relationship between Barrett metaplasia and eosinophilic infiltrates in the esophageal mucosa. Although the influence of diagnostic bias cannot be excluded, the possibility that eosinophilic infiltrates in the esophageal mucosa prevent subsequent metaplastic changes may deserve to be explored.

[Barrett's esophagus. An update]

Barrett's esophagus (BE), a well-known complication of gastroesophageal reflux disease (GERD), constitutes a precancerous condition for adenocarcinoma of the distal esophagus. The so-called Barrett's carcinoma shows increasing incidences in countries of the western hemisphere; new data, however, indicate that the rise in incidence is not quite as dramatic as previously assumed. The definition of BE is currently changing: despite good reasons for a purely endoscopic definition of BE, goblet cells are still mandatory for this diagnosis in Germany and the USA. Dysplastic changes in the epithelium are the most important risk factor for the development of Barrett's adenocarcinoma and recently dysplasia was subclassified into a more frequent adenomatous (intestinal) and a non-adenomatous (gastric-foveolar) types. The gold standard for diagnosing dysplasia is still H&E staining. The histological diagnosis of dysplasia is still encumbered by a significant interobserver variability, especially regarding the differentiation between low grade dysplasia and inflammatory/reactive changes and the discrimination between high grade dysplasia and adenocarcinoma. Current data, however, show much higher interobserver agreement in endoscopic resection specimens than in biopsies. Nevertheless, the histological diagnosis of dysplasia should be corroborated by an external second opinion because of its clinical consequences. In endoscopic resections of early Barrett's adenocarcinoma, the pathological report has to include a risk stratification for the likelihood of lymphogenic metastases.

Divergent expression of MUC5AC, MUC6, MUC2, CD10, and CDX-2 in dysplasia and intramucosal adenocarcinomas with intestinal and foveolar morphology: is this evidence of distinct gastric and intestinal pathways to carcinogenesis in Barrett Esophagus?

Dysplasia in Barrett esophagus has been recognized to be morphologically heterogenous, featuring adenomatous, foveolar, and hybrid phenotypes. Recent studies have suggested a tumor suppressor role for CDX-2 in the metaplasia-dysplasia-carcinoma sequence. The phenotypic stability and role of CDX-2 in the neoplastic progression of different types of dysplasias have not been evaluated. Thirty-eight endoscopic mucosal resections with dysplasia and/or intramucosal carcinoma (IMC) arising in Barrett esophagus were evaluated for the expression of MUC5AC, MUC6, MUC2, CD10, and CDX-2. The background mucosa was also evaluated. The results were correlated with morphologic classification and clinicopathologic parameters. Of 38 endoscopic mucosal resections, 23 had IMC and dysplasia, 8 had IMC only, and 7 had dysplasia only. Among dysplastic lesions, 73% were foveolar, 17% were adenomatous, and 10% were hybrid. Twenty of 23 cases with dysplasia and adjacent IMC showed an identical immunophenotype of dysplasia and IMC comprising 16 gastric, 3 intestinal, and 1 mixed immunophenotype. Three cases showed discordance of dysplasia and IMC immunophenotype. These findings suggest that most Barrett-related IMC cases are either gastric or intestinal, with phenotypic stability during progression supporting separate gastric and intestinal pathways of carcinogenesis. CDX-2 showed gradual downregulation of expression during progression in adenomatous dysplasia but not in foveolar or hybrid dysplasia, supporting a tumor suppressor role, at least in the intestinal pathway. CDX-2 was also found to be expressed to a greater degree in intestinal metaplasia compared with nonintestinalized columnar metaplasia. Consistent with CDX-2 as a tumor suppressor, this suggests that nonintestinalized columnar metaplasia may be an unstable intermediate state at risk for neoplastic progression.

Low prevalence of Helicobacter pylori infection among patients with inflammatory bowel disease

BACKGROUND

There is some preliminary evidence to suggest that patients with inflammatory bowel disease (IBD) are less frequently infected with Helicobacter pylori than the general population.

AIM

To examine whether the prevalence of Helicobacter pylori (H. pylori) is lower among IBD patients compared with non-IBD individuals based on results from surgical pathology.

METHODS

From a database of surgical pathology reports, we recruited a sample of unique patients who underwent a same-day bidirectional gastrointestinal endoscopy with biopsies. Of the total 65,515 patients, 1061 served as cases with IBD and 64,451 as controls without IBD. The histological presence of H. pylori was correlated with the patients' demographic characteristics and histological presence of any oesophageal disease, Crohn's disease (CD), ulcerative colitis (UC) and indeterminate colitis (IND). Results were expressed as odds ratios (OR), using multivariate logistic regression to adjust for the cofounding influence of comorbidities and demographic characteristics.

RESULTS

The presence of H. pylori was inversely associated with IBD, the adjusted OR and their 95% confidence intervals being 0.48 (0.27-0.79) for CD, 0.59 (0.39-0.84) for UC and 0.43 (0.15-0.95) for IND. In contradistinction, H. pylori-negative gastritis was positively associated with IBD, the adjusted OR being 11.06 (7.98-15.02) for CD, 2.25 (1.31-3.60) for UC and 6.91 (3.50-12.30) for IND.

CONCLUSIONS

Our study confirms an inverse association between H. pylori and IBD and a positive association between the H. pylori-negative gastritis and IBD. These relationships may open new avenues to study the pathogenesis of IBD.

Hepatocyte paraffin 1 antigen as a biomarker for early diagnosis of Barrett esophagus

We evaluated hepatocyte paraffin 1 (HepPar1) antigen expression, a sensitive marker of small intestinal differentiation, in combination with morphologic features to demonstrate intestinal differentiation in cases equivocal for Barrett esophagus (BE). Clinicopathologic features and HepPar1 expression were recorded for 54 BE cases, 45 consistent with reflux esophagitis (RE) cases, and 65 "suspicious" for BE (SBE) cases. The SBE category included RE cases with 2 or more morphologic changes associated with BE or metaplastic reaction to injury (eg, multilayered epithelium, squamous islands, goblet cell mimickers, pancreatic metaplasia). HepPar1 was expressed in all 54 BE cases, 4 of 45 RE cases, and 24 of 65 SBE cases. In SBE cases, 2 or more morphologic changes were associated with HepPar1 expression in 37% of cases (24/65), 3 or more features in 59% (13/22), and 4 or more features in 100% (4/4) (P ≤ .004). The combination of certain morphologic changes and HepPar1 expression in clinically suspicious distal esophageal biopsy cases without goblet cells supports the presence of evolving intestinal metaplasia.

Esophageal disease and pathology

The following on esophageal disease and pathology contains commentaries on the varied definitions of Barrett's esophagus (BE); the optimal biopsy strategy in BE; reliable biomarkers for progression to neoplasia in BE; and the role of bone marrow stem cells in the morphogenesis of Barrett's esophagus.

A Clinical and Histopathologic Focus on Barrett Esophagus and Barrett-Related Dysplasia

Context.—Barrett esophagus is a metaplastic, premalignant lesion associated with approximately 0.5% annual incidence of progression to esophageal adenocarcinoma. Diagnosis and screening of Barrett esophagus and Barrett-related dysplasia relies on histologic evaluation of endoscopic mucosal biopsies, a process that is burdened with interobserver variability.

Objectives.—To review the histologic features and classification of Barrett esophagus and Barrett-related dysplasia, to discuss the underlying difficulties in diagnosis and pitfalls, and to provide a brief review of new developments related to therapeutic modalities for patients diagnosed with dysplasia.

Data Sources.—Sources include a review of relevant literature indexed in PubMed (US National Library of Medicine).

Conclusions.—In spite of interobserver variability, histologic assessment of dysplasia is currently the accepted method of surveillance, and subsequent patient management is dictated by this evaluation. Although not universal, endoscopic therapy is increasingly important in replacing esophagectomy for patients with high-grade dysplasia or early carcinoma.

The dichotomy in carcinogenesis of the distal esophagus and esophagogastric junction: intestinal-type vs cardiac-type mucosa-associated adenocarcinoma

Adenocarcinoma of the distal esophagus and esophagogastric junction continues to rise in incidence. An intestinal metaplasia (Barrett esophagus)-dysplasia-carcinoma sequence induced by gastroesophageal reflux disease is well established. However, a significant number of adenocarcinomas in the vicinity of the esophagogastric junction are seen in the background of gastric/cardiac-type mucosa without intestinal metaplasia. Thus, the aim of this study was to investigate the role of Barrett esophagus (intestinal-type mucosa) in the classification and prognosis of tumors of the distal esophagus and esophagogastric junction. Clinicopathological and molecular characteristics were examined in 157 consecutively resected adenocarcinomas of the distal esophagus and esophagogastric junction and were compared between tumors arising in association with intestinal-type and cardiac-type mucosa. Intestinal-type mucosa-associated adenocarcinomas were more likely to be associated with younger age (P=0.0057), reflux symptoms (P<0.0001), proximal location (P=0.0009), lower T stage (P<0.0001), fewer nodal metastases (P=0.0001), absence of lymphatic (P<0.0001), venous (P=0.0060) or perineural (P<0.0001) invasion. Histologically, intestinal-type mucosa-associated tumors were more likely to be low-grade glandular tumors (P=0.0095) of intestinal or mixed immunophenotype (P=0.015) and express nuclear β-catenin (P=0.0080), whereas tumors arising in a background of cardiac-type mucosa were more frequently associated with EGFR amplification (P=0.0051). Five-year overall survival rate was significantly higher in patients with intestinal-type mucosa-associated tumors (28 vs 9%, P=0.0015), although no survival benefit was seen after adjusting for potential confounders. Our findings support the theory that multiple distinct pathways of tumorigenesis exist in the vicinity of the esophagogastric junction, including one in which tumors arise from dysplastic intestinal metaplasia (intestinal pathway), and one potentially involving dysplasia of the cardiac-type mucosa (non-intestinal pathway). Additional studies are warranted to further clarify their pathogenesis and the molecular mechanisms involved.

MUC2 is a highly specific marker of goblet cell metaplasia in the distal esophagus and gastroesophageal junction

Currently, the American College of Gastroenterology requires identification of goblet cells in mucosal biopsies from the esophagus to diagnose Barrett esophagus (BE). Identification of goblet cells in mucosal biopsies is fraught with limitations such as sampling and interpretation error. One previous study by our group suggested that MUC2 expression in esophageal nongoblet columnar cells represents a late biochemical reaction in the conversion of mucinous columnar cells to goblet cells in BE. We conducted this study to evaluate the prevalence, sensitivity, and specificity of MUC2 positivity in nongoblet columnar epithelium for detection of goblet cells in the distal esophagus and gastroesophageal junction (GEJ) region. We also sought to identify associations between MUC2 positivity and clinical and endoscopic risk factors for BE. This analysis utilized mucosal biopsies of the distal esophagus or GEJ from 100 patients who participated in a community clinic-based study of patients with chronic gastroesophageal reflux disease evaluated prospectively in the western part of Washington state. We randomly selected 50 patients who had columnar epithelium with goblet cells, representing the study group and 50 patients without goblet cells, representing the comparison group. Immunohistochemistry for MUC2 was performed on samples in a blinded manner without knowledge of the clinical or endoscopic features of the patients. The presence of staining was noted in both goblet and nongoblet epithelium, both close to and distant from the mucosa with goblet cells, when the latter were present. All study patients showed MUC2 positivity in goblet cells. MUC2 was present in nongoblet columnar epithelium in 78% of study patients with goblet cells, but in only 4% of controls without goblet cells (P<0.0001) (sensitivity, 78%; specificity, 96% for goblet cell metaplasia). MUC2 was significantly more common in nongoblet columnar cells close to, rather than distant from, the mucosa with goblet cells (P<0.00001). Finally, MUC2 was significantly associated with endoscopic evidence of columnar metaplasia in the distal esophagus, and with known risk factors for BE, such as older age, white race, frequent heartburn, and elevated body mass index. We conclude that goblet cells likely develop from a field of MUC2-positive mucinous columnar cells, and as such, MUC2 represents a late event in the development of goblet cells. MUC2 staining in nongoblet columnar cells is a reasonably sensitive and highly specific marker for goblet cells in the distal esophagus and GEJ, and its presence is predictive of endoscopic columnar metaplasia of the esophagus, even in patients without goblet cells.

Comparison of intestinal metaplasia in gastric cardia and Barrett's esophagus

OBJECTIVE

To evaluate and compare the pathological features and immunostaining pattern (cytokeratin 7 (CK-7), mucin core peptide 1 (Muc-1)) in Barrett's esophagus (BE) and cardiac intestinal metaplasia (CIM).

METHODS

According to endoscopic diagnosis, patients with gastric cardiac inflammation and BE were selected from March 2008 to February 2009 in Renji Hospital, Shanghai Jiaotong University School of Medicine. Those patients who had histological findings of intestinal metaplasia (82 cases of CIM and 64 special type BE) were enrolled in our study. Hematoxylin-eosin, periodic acid-Schiff and Alcian blue staining and an immunohistochemical examination (CK-7, Muc-1) were undertaken in all of them.

RESULTS

Squamous mucosa overlying the columnar crypts with intestinal metaplasia, also called buried metaplasia, was often found in the BE group (56.2%), mainly as an incomplete type (85.9%). Inflammation in the gastric antrum was more severe in the CIM group (45.1% vs 26.6%), in contrast, esophagitis was more severe in the BE group (53.1% vs 35.4%). CK-7 was highly expressed in the BE group (84.4%) in contrast to the CIM group (37.8%). There was no difference in the expression of Muc-1 in these two kinds of intestinal metaplasia (14.1% vs 19.5%).

CONCLUSIONS

Buried intestinal metaplasia, mainly as an incomplete type, is the major predominant type of BE. The degree of inflammation in the gastric antrum and esophagus can differentiate BE from CIM to some extent. CK-7 immunohistochemical staining can help identify BE and CIM but Muc-1 cannot.