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Umar N, Alleyne L, Cheung D, Rees J, Trudgill C, Zanetto U, Muzaffar S, Trudgill N. Variation in proliferative and cell cycle markers in Barrett's esophagus in relation to circumferential and axial location in the esophagus. Eur J Gastroenterol Hepatol 2024; 36:306-312. [PMID: 38251437 DOI: 10.1097/meg.0000000000002700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Abstract
BACKGROUND Adenocarcinoma in Barrett's esophagus (BE) occurs more frequently between 12 and 3 o'clock at the gastroesophageal junction (GEJ). METHODS BE patients were prospectively recruited from December 2013 to July 2016. Expression of p53, Ki-67, cyclin-D1, COX-2 and p21 was assessed in quadrantic biopsies from the proximal and distal margins of the BE segments. Cell cycle marker association with current or subsequent dysplasia or adenocarcinoma was examined. RESULTS 110 patients: median age 64 (IQR, 56-71) years; median BE segment length C4M6; and a median follow-up of 4.7 (IQR, 3.6-5.7) years. In total 13 (11.8%) had evidence of dysplasia or neoplasia (2.7% indefinite for dysplasia, 5.5% low grade, 1.8% high grade and 1.8% adenocarcinoma) at index endoscopy. Six (7%) developed dysplasia or neoplasia (1 low grade, 2 high grade and 3 adenocarcinoma) during follow-up. Ki-67 expression was highest at 3 o'clock, and overall was 49.6% higher in the 12-6 o'clock position compared to 6-12 o'clock [odds ratio (OR), 1.42 (95% confidence interval (CI), 1.00-2.12)]. A similar pattern was found with p21 [1.82 (1.00-3.47)]. There was increased expression of several markers in distal BE biopsies; cyclin-D1 [1.74 (1.29-2.34)]; Cyclo-oxygenase 2 [2.03 (1.48-2.78]) and p21 [2.06 (1.16-3.68)]. Expression of Ki-67 was lower in distal compared to proximal biopsies [0.58 (0.43-0.78)]. P53 expression had high specificity (93.8%) for subsequent low-grade dysplasia, high-grade dysplasia or adenocarcinoma. CONCLUSION Increased cellular proliferation was seen at 12-6 o'clock at the GEJ. Cell-cycle marker expression was increased at the GEJ compared to the proximal BE segment. These findings mirror reflux esophagitis and suggest ongoing reflux contributes to the progression of dysplasia and malignancy in BE.
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Affiliation(s)
- Nosheen Umar
- Sandwell and West Birmingham NHS Trust, West Bromwich, UK
| | - Lance Alleyne
- Sandwell and West Birmingham NHS Trust, West Bromwich, UK
| | - Danny Cheung
- Worcestershire Acute Hospitals NHS Trust, Worcester, UK
| | - James Rees
- Worcestershire Acute Hospitals NHS Trust, Worcester, UK
| | | | | | | | - Nigel Trudgill
- Sandwell and West Birmingham NHS Trust, West Bromwich, UK
- Institute of Cancer and Genomic Sciences, University of Birmingham, UK
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Olmos JA, Pandolfino JE, Piskorz MM, Zamora N, Valdovinos Díaz MA, Remes Troche JM, Guzmán M, Hani A, Valdovinos García LR, Pitanga Lukashok H, Domingues G, Vesco E, Rivas MM, Ovalle LFP, Cisternas D, Vela MF. Latin American consensus on diagnosis of gastroesophageal reflux disease. Neurogastroenterol Motil 2024; 36:e14735. [PMID: 38225792 DOI: 10.1111/nmo.14735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 12/05/2023] [Accepted: 12/18/2023] [Indexed: 01/17/2024]
Abstract
BACKGROUND Diagnosing gastroesophageal reflux disease (GERD) can be challenging given varying symptom presentations, and complex multifactorial pathophysiology. The gold standard for GERD diagnosis is esophageal acid exposure time (AET) measured by pH-metry. A variety of additional diagnostic tools are available. The goal of this consensus was to assess the individual merits of GERD diagnostic tools based on current evidence, and provide consensus recommendations following discussion and voting by experts. METHODS This consensus was developed by 15 experts from nine countries, based on a systematic search of the literature, using GRADE (grading of recommendations, assessment, development and evaluation) methodology to assess the quality and strength of the evidence, and provide recommendations regarding the diagnostic utility of different GERD diagnosis tools, using AET as the reference standard. KEY RESULTS A proton pump inhibitor (PPI) trial is appropriate for patients with heartburn and no alarm symptoms, but nor for patients with regurgitation, chest pain, or extraesophageal presentations. Severe erosive esophagitis and abnormal reflux monitoring off PPI are clearly indicative of GERD. Esophagram, esophageal biopsies, laryngoscopy, and pharyngeal pH monitoring are not recommended to diagnose GERD. Patients with PPI-refractory symptoms and normal endoscopy require reflux monitoring by pH or pH-impedance to confirm or exclude GERD, and identify treatment failure mechanisms. GERD confounders need to be considered in some patients, pH-impedance can identify supragrastric belching, impedance-manometry can diagnose rumination. CONCLUSIONS Erosive esophagitis on endoscopy and abnormal pH or pH-impedance monitoring are the most appropriate methods to establish a diagnosis of GERD. Other tools may add useful complementary information.
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Affiliation(s)
- Jorge A Olmos
- Neurogastroenterology Sector, Hospital de Clinicas Jose de San Martin, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - John E Pandolfino
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - María M Piskorz
- Neurogastroenterology Sector, Hospital de Clinicas Jose de San Martin, Universidad de Buenos Aires, Buenos Aires, Argentina
| | | | - Miguel A Valdovinos Díaz
- UNAM, Ciudad de Mexico, Mexico
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - José M Remes Troche
- Institute of Medical Biological Research, Universidad Veracruzana, Veracruz, Mexico
| | - Mauricio Guzmán
- Neurogastroenterology Unit, Gastroenterology Service, Hospital San Martín de La Plata, Buenos Aires, Argentina
| | - Albis Hani
- Hospital San Ignacio-Pontificia Universidad Javeriana, Bogotá, Colombia
| | | | - Hannah Pitanga Lukashok
- Digestive Motility Service, Instituto Ecuatoriano de Enfermedades Digestivas-IECED, Guayaquil, Ecuador
| | | | - Eduardo Vesco
- Neuromotility Unit, Clínica Angloamericana, Lima, Peru
- Universidad Nacional Mayor de San Marcos, Lima, Peru
| | - Mariel Mejia Rivas
- Internal Medicine, Gastroenterology and Digestive Endoscopy Service, Hospital Vivian Pellas, Managua, Nicaragua
| | - Luis F Pineda Ovalle
- Neurogastroenterology and Motility Service Motility Instituto Gut Médica, Bogotá, Colombia
| | - Daniel Cisternas
- Clínica Alemana de Santiago, School of Medicine, Universidad del Desarrollo, Clínica Alemana, Vitacura, Chile
| | - Marcelo F Vela
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
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3
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Yamada A, Hoshihara Y, Hoshikawa Y, Momma E, Koeda M, Hoshino S, Kawami N, Iwakiri K. Evaluation of the circumferential location of mild reflux esophagitis (Grade A and B) in the lower esophagus. JGH Open 2022; 6:864-868. [PMID: 36514497 PMCID: PMC9730706 DOI: 10.1002/jgh3.12834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 10/10/2022] [Accepted: 10/15/2022] [Indexed: 11/09/2022]
Abstract
Background and Aim Discrepancies have been reported in the circumferential locations of mild mucosal breaks. We investigated their locations using a new method. Methods This is a retrospective study. Eighty patients (Grade A/B: 53/27) with mild mucosal breaks in the lower esophagus were examined. Since the 3 o'clock position corresponded to the right wall of the lower esophagus using our method with sufficient accuracy, the circumferential locations of mucosal breaks were identified as times on a clock face, which were changed to circular data to calculate the mean direction. The circumferential distribution of mucosal breaks was evaluated in the single lesion group (single group) and multiple lesion group (multiple group). Results Forty-eight of 80 patients had 1 mucosal break, while 32 had ≥2 mucosal breaks. Circumferential locations markedly differed between the single and multiple groups. In the single group, mucosal breaks were exclusively distributed between 2 and 7 o'clock, with 50% in the 3 o'clock direction (right wall). In the multiple group, 81 mucosal breaks were distributed circumferentially, not uniformly; however, at least 1 lesion was located between 2 and 7 o'clock in 91% of subjects. Therefore, a factor for the development of mucosal breaks from the right to posterior wall was present in both groups. Conclusion In the single group, mucosal breaks were localized from the right to posterior wall, mainly in the right wall. In the multiple group, mucosal breaks were located circumferentially, but often between the right lateral and posterior wall. These two distributions significantly differed.Clinical trial registration: This is a retrospective study, so it was not registered.
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Affiliation(s)
- Akiyoshi Yamada
- Department of Gastroenterology, Nippon Medical SchoolGraduate School of MedicineTokyoJapan
| | - Yoshio Hoshihara
- Department of Gastroenterology, Nippon Medical SchoolGraduate School of MedicineTokyoJapan
| | - Yoshimasa Hoshikawa
- Department of Gastroenterology, Nippon Medical SchoolGraduate School of MedicineTokyoJapan
| | - Eri Momma
- Department of Gastroenterology, Nippon Medical SchoolGraduate School of MedicineTokyoJapan
| | - Mai Koeda
- Department of Gastroenterology, Nippon Medical SchoolGraduate School of MedicineTokyoJapan
| | - Shintaro Hoshino
- Department of Gastroenterology, Nippon Medical SchoolGraduate School of MedicineTokyoJapan
| | - Noriyuki Kawami
- Department of Gastroenterology, Nippon Medical SchoolGraduate School of MedicineTokyoJapan
| | - Katsuhiko Iwakiri
- Department of Gastroenterology, Nippon Medical SchoolGraduate School of MedicineTokyoJapan
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Wu J, Ma Y, Chen Y. GERD-related chronic cough: Possible mechanism, diagnosis and treatment. Front Physiol 2022; 13:1005404. [PMID: 36338479 PMCID: PMC9630749 DOI: 10.3389/fphys.2022.1005404] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 10/07/2022] [Indexed: 11/04/2023] Open
Abstract
GERD, or gastroesophageal reflux disease, is a prevalent medical condition that affects millions of individuals throughout the world. Chronic cough is often caused by GERD, and chronic cough caused by GER is defined as GERD-related chronic cough (GERC). It is still unclear what the underlying molecular mechanism behind GERC is. Reflux theory, reflex theory, airway allergies, and the novel mechanism of esophageal motility disorders are all assumed to be linked to GERC. Multichannel intraluminal impedance combined with pH monitoring remains the gold standard for the diagnosis of GERC, but is not well tolerated by patients due to its invasive nature. Recent discoveries of new impedance markers and new techniques (mucosal impedance testing, salivary pepsin, real-time MRI and narrow band imaging) show promises in the diagnosis of GERD, but the role in GERC needs further investigation. Advances in pharmacological treatment include potassium-competitive acid blockers and neuromodulators (such as Baclofen and Gabapentin), prokinetics and herbal medicines, as well as non-pharmacological treatments (such as lifestyle changes and respiratory exercises). More options have been provided for the treatment of GERC other than acid suppression therapy and anti-reflux surgery. In this review, we attempt to review recent advances in GERC mechanism, diagnosis, and subsequent treatment options, so as to provide guidance for management of GERC.
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Affiliation(s)
| | - Yiming Ma
- Department of Pulmonary and Critical Care Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yan Chen
- Department of Pulmonary and Critical Care Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
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5
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Chen S, Du F, Zhong C, Liu C, Wang X, Chen Y, Wang G, Gao X, Zhang L, Li L, Wu W. Gastroesophageal reflux disease: recent innovations in endoscopic assessment and treatment. Gastroenterol Rep (Oxf) 2021; 9:383-391. [PMID: 34733523 PMCID: PMC8560030 DOI: 10.1093/gastro/goab029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 06/17/2021] [Accepted: 06/18/2021] [Indexed: 12/19/2022] Open
Abstract
Innovations in endoscopy have brought about some impressive improvements in diagnosing and treating gastroesophageal reflux disease (GERD). GERD, as one of the most prevalent gastrointestinal disorders in the world, has always been on the cutting edge of endoscopic interventions. A primary diagnosis of GERD is based on symptoms and an initial trial of proton-pump inhibitor (PPI) therapy, which is devoid of adequately instructive value for therapeutic strategies. Endoscopy and optional biopsies can be used to directly observe and determine the abnormal structural and pathophysiological damage in the esophagus. The emergence of minimally invasive endoscopic therapy fills the gap between patients who are reluctant or insensitive to PPIs and candidates who are not indicated for surgical anti-reflux fundoplication. In this review, we discuss the utility of endoscopy and biopsy in patients with persistent GERD-related manifestations after proper medical anti-reflux treatment. Moreover, we portray a landscape of four current endoscopic GERD therapies and clarify the merits and disadvantages of each technique. Future research needs to concentrate on stratifying GERD patients based on personal conditions and elucidating the primary pathophysiology of GERD.
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Affiliation(s)
- Sheng Chen
- Department of Gastroenterology, PLA Strategic Support Force Characteristic Medical Center, Beijing, P. R. China
- State Environmental Protection Key Laboratory of Environmental Sense Organ Stress and Health, PLA Strategic Support Force Characteristic Medical Center, Beijing, P. R. China
| | - Feng Du
- Department of Gastroenterology, PLA Strategic Support Force Characteristic Medical Center, Beijing, P. R. China
- Department of Internal Medicine, The Hospital of the People's Liberation Army 63650 Corps, Malan, Xinjiang, P. R. China
| | - Changqing Zhong
- Department of Gastroenterology, PLA Strategic Support Force Characteristic Medical Center, Beijing, P. R. China
| | - Caifang Liu
- Department of Pediatrics, The First Affiliated Hospital of Xi'an Medical University, Xi’an, Shaanxi, P. R. China
| | - Xiaoying Wang
- Department of Gastroenterology, PLA Strategic Support Force Characteristic Medical Center, Beijing, P. R. China
| | - Yan Chen
- Department of Gastroenterology, PLA Strategic Support Force Characteristic Medical Center, Beijing, P. R. China
| | - Gang Wang
- State Environmental Protection Key Laboratory of Environmental Sense Organ Stress and Health, PLA Strategic Support Force Characteristic Medical Center, Beijing, P. R. China
- Department of Otorhinolaryngology Head and Neck Surgery, PLA Strategic Support Force Characteristic Medical Center, Beijing, P. R. China
| | - Xiaopei Gao
- Department of Gastroenterology, PLA Strategic Support Force Characteristic Medical Center, Beijing, P. R. China
| | - Lu Zhang
- Department of Gastroenterology, PLA Strategic Support Force Characteristic Medical Center, Beijing, P. R. China
| | - Lianyong Li
- Department of Gastroenterology, PLA Strategic Support Force Characteristic Medical Center, Beijing, P. R. China
| | - Wei Wu
- State Environmental Protection Key Laboratory of Environmental Sense Organ Stress and Health, PLA Strategic Support Force Characteristic Medical Center, Beijing, P. R. China
- Department of Otorhinolaryngology Head and Neck Surgery, PLA Strategic Support Force Characteristic Medical Center, Beijing, P. R. China
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6
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Kaymak T, Hruz P, Niess JH. Immune system and microbiome in the esophagus: implications for understanding inflammatory diseases. FEBS J 2021; 289:4758-4772. [PMID: 34213831 PMCID: PMC9542113 DOI: 10.1111/febs.16103] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 05/20/2021] [Accepted: 07/01/2021] [Indexed: 12/15/2022]
Abstract
The gastrointestinal tract is the largest compartment of the body's immune system exposed to microorganisms, structural components and metabolites, antigens derived from the diet, and pathogens. Most studies have focused on immune responses in the stomach, the small intestine, and the colon, but the esophagus has remained an understudied anatomic immune segment. Here, we discuss the esophagus' anatomical and physiological distinctions that may account for inflammatory esophageal diseases.
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Affiliation(s)
- Tanay Kaymak
- Department of Biomedicine, University of Basel, Switzerland
| | - Petr Hruz
- Clarunis - University Center for Gastrointestinal and Liver Diseases Basel, Switzerland
| | - Jan Hendrik Niess
- Department of Biomedicine, University of Basel, Switzerland.,Clarunis - University Center for Gastrointestinal and Liver Diseases Basel, Switzerland
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7
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Raphael KL, Inamdar S, McKinley MJ, Martinez N, Cavaliere K, Kahn A, Leggett CL, Iyer P, Wang KK, Trindade AJ. Longitudinal and Circumferential Distributions of Dysplasia and Early Neoplasia in Barrett's Esophagus: A Pooled Analysis of Three Prospective Studies. Clin Transl Gastroenterol 2021; 12:e00311. [PMID: 33617190 PMCID: PMC7901801 DOI: 10.14309/ctg.0000000000000311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 12/29/2020] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Studies have shown that dysplasia in Barrett's esophagus (BE) has a predilection for the right hemisphere. There is limited information on the longitudinal distribution. The aim was to determine both the longitudinal and circumferential distributions of dysplasia and early neoplasia from 3 prospective studies. METHODS This is a pooled analysis from 3 prospective studies of patients with treatment-naive BE. Both circumferential and longitudinal locations (for BE segments greater than 1 cm) of dysplastic and early neoplastic lesions were recorded. RESULTS A total of 177 dysplastic and early neoplastic lesions from 91 patients were included in the pooled analysis; of which 59.3% (n = 105) were seen on high-definition white light endoscopy, 29.4% (n = 52) on advanced imaging, and 11.2% (n = 20) with random biopsies. The average Prague score was C3M5. Of 157 lesions within BE segments greater than 1 cm, 49 (34.8%) lesions were in the proximal half, whereas 92 lesions (65.2%) were in the distal half (P < 0.001). The right hemisphere of the esophagus contained 55% (86/157) of the total lesions compared with 45% (71/157) for the left hemisphere (P = 0.02). This was because of the presence of high-grade dysplasia being concentrated in the right hemisphere compared with the left hemisphere (60% vs 40%, P = 0.002). DISCUSSION In this pooled analysis of prospective studies, both low-grade dysplasia and high-grade dysplasia are more frequently found in the distal half of the Barrett's segment. This study confirms that the right hemisphere is a hot spot for high-grade dysplasia. Careful attention to these locations is important during surveillance endoscopy.
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Affiliation(s)
- Kara L Raphael
- Division of Gastroenterology, Long Island Jewish Medical Center, Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, New Hyde Park, New York, USA
| | - Sumant Inamdar
- Division of Gastroenterology, University of Arkansas, Little Rock, Arkansas, USA
| | - Matthew J McKinley
- Division of Gastroenterology, Long Island Jewish Medical Center, Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, New Hyde Park, New York, USA
| | - Nichol Martinez
- Division of Gastroenterology, Long Island Jewish Medical Center, Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, New Hyde Park, New York, USA
| | - Kimberly Cavaliere
- Division of Gastroenterology, Long Island Jewish Medical Center, Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, New Hyde Park, New York, USA
| | - Allon Kahn
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA ; and
| | - Cadman L Leggett
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Prasad Iyer
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Kenneth K Wang
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Arvind J Trindade
- Division of Gastroenterology, Long Island Jewish Medical Center, Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, New Hyde Park, New York, USA
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Hoshihara Y, Yamada A, Hoshino S, Hoshikawa Y, Kawami N, Aida J, Takubo K, Iwakiri K. Defining the Position of the Right Wall of the Esophageal Hiatus to Identify the Circumferential Distribution of Small Lesions of the Lower Esophagus. J NIPPON MED SCH 2020; 88:32-38. [PMID: 32238738 DOI: 10.1272/jnms.jnms.2021_88-102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND The reliability of methods for identifying the circumferential position of small lower esophageal lesions is unknown. We prospectively investigated a new method that presents lesion positions as times on a clock face. METHODS Eighty-seven patients were consecutively examined by endoscopy. After observing the esophagus, an endoscope was inserted into the stomach and fixed, and the greater curvature folds at the upper gastric corpus were set as horizontal on the endoscope monitor display. The scope was retrogressed into the lower esophagus. At this point, the right wall at the hiatus is at the 3 o'clock position (R-line). The scope was then retrogressed from the gastric angle to the cardia along the center of the lesser curvature in the retroflexed view to obtain the LC-line (the center of the lesser curvature at the cardia). The LC-line in the esophageal hiatus in the frontal view was then identified, and the angle between the R- and LC-lines (R-LC) was measured. RESULTS After excluding 7 patients with hernias >2 cm and 3 with esophageal stenosis, data from 77 patients were analyzed. The R-LC angle ranged from -38° to +35°. The mean R-LC angle was -0.3°± 15.9°, and its 95% confidence interval was [-4.0°, 3.3°] within [-15°, + 15°]. When indicating lesion locations as times on a clock face, there was an error of ±30 min (±15°); therefore, R- and LC-lines were shown to be identical on an equivalence test. CONCLUSIONS This new method allows the circumferential position of small lower esophageal lesions to be reliably represented as a clock face.
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Affiliation(s)
- Yoshio Hoshihara
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine
| | - Akiyoshi Yamada
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine
| | - Shintaro Hoshino
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine
| | - Yoshimasa Hoshikawa
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine
| | - Noriyuki Kawami
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine
| | - Junko Aida
- Research Team for Geriatric Pathology, Tokyo Metropolitan Institute of Gerontology
| | - Kaiyo Takubo
- Research Team for Geriatric Pathology, Tokyo Metropolitan Institute of Gerontology
| | - Katsuhiko Iwakiri
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine
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Emura F, Gomez-Esquivel R, Rodriguez-Reyes C, Benias P, Preciado J, Wallace M, Giraldo-Cadavid L. Endoscopic identification of endoluminal esophageal landmarks for radial and longitudinal orientation and lesion location. World J Gastroenterol 2019; 25:498-508. [PMID: 30700945 PMCID: PMC6350169 DOI: 10.3748/wjg.v25.i4.498] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Revised: 12/03/2018] [Accepted: 12/20/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To characterize esophageal endoluminal landmarks to permit radial and longitudinal esophageal orientation and accurate lesion location.
METHODS Distance from the incisors and radial orientation were estimated for the main left bronchus and the left atrium landmarks in 207 consecutive patients using white light examination. A sub-study was also performed using white light followed by endoscopic ultrasound (EUS) in 25 consecutive patients to confirm the findings. The scope orientation throughout the exam was maintained at the natural axis, where the left esophageal quadrant corresponds to the area between 6 and 9 o’clock. When an anatomical landmark was identified, it was recorded with a photograph and its quadrant orientation and distance from the incisors were determined. The reference points to obtain the distances and radial orientation were as follows: the midpoint of the left main bronchus and the most intense pulsatile zone of the left atrium. With the video processor system set to moderate insufflation, measurements were obtained at the end of the patients’ air expiration.
RESULTS The left main bronchus and left atrium esophageal landmarks were identified using white light in 99% and 100% of subjects at a mean distance of 25.8 cm (SD 2.3), and 31.4 cm (SD 2.4) from the incisors, respectively. The left main bronchus landmark was found to be a tubular, concave, non-pulsatile, esophageal external compression, occupying approximately 1/4 of the circumference. The left atrium landmark was identified as a round, convex, pulsatile, esophageal external compression, occupying approximately 1/4 of the circumference. Both landmarks were identified using white light on the anterior esophageal quadrant. In the sub-study, the left main bronchus was identified in 24 (92%) patients at 25.4 cm (SD 2.1) and 26.7 cm (SD 1.9) from the incisors, by white light and EUS, respectively. The left atrium was recognized in all patients at 30.5 cm (SD 1.9), and 31.6 cm (SD 2.3) from the incisors, by both white light and EUS, respectively. EUS confirmed that the landmarks corresponded to these two structures, respectively, and that they were located on the anterior esophageal wall. The Bland-Altman plot demonstrated high agreement between the white light and EUS measurements.
CONCLUSION This study provides an endoscopic characterization of esophageal landmarks corresponding to the left main bronchus and left atrium, to permit radial and longitudinal orientation and accurate lesion location.
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Affiliation(s)
- Fabian Emura
- Division of Gastroenterology, Universidad de La Sabana, Bogotá DC 140013, Colombia
- Advanced Gastrointestinal Endoscopy, EmuraCenter LatinoAmerica, Bogotá DC 110121, Colombia
- Emura Foundation for the Promotion of Cancer Research, Bogotá DC 110121, Colombia
- Unidad de Endoscopia Digestiva, Clínica Pediátrica Colsanitas, Bogotá DC 110121, Colombia
| | - Rene Gomez-Esquivel
- Division of Digestive Diseases and Nutrition, Morsani College of Medicine, University of South Florida, Tampa, FL 33612, United States
| | | | - Petros Benias
- Division of Gastroenterology, North Shore-Long Island Jewish Medical Center. New York, NY 11030, United States
| | - Javier Preciado
- Unidad de Exploraciones Digestivas, Clinica Universitaria Colombia, Bogotá DC 110121, Colombia
| | - Michael Wallace
- Department of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL 32224, United States
| | - Luis Giraldo-Cadavid
- Department of Internal Medicine. Universidad de La Sabana, Bogotá DC 140013, Colombia
- Division of Interventional Pulmonology, Fundacion Neumologica Colombiana, Bogota DC, 110131, Colombia
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10
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Adachi K, Notsu T, Mishiro T, Okada M, Okimoto E, Kinoshita Y. Vertical and Circumferential Localization of Esophageal Mucosal Breaks in Patients with Mild Reflux Esophagitis. Intern Med 2019; 58:15-20. [PMID: 30101941 PMCID: PMC6367093 DOI: 10.2169/internalmedicine.1356-18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Objective Esophageal mucosal breaks are considered to occur circumferentially in locations with high exposure to acid. In the present study, we investigated the circumferential localization of esophageal mucosal breaks based on their distance from the esophagogastric junction. Methods The vertical and circumferential localization of 625 esophageal longitudinal mucosal breaks was examined in 398 patients with mild reflux esophagitis. Results The number of mucosal breaks in which the distal end was located 0-1 cm from the esophagogastric junction was 454, while those in which the distal end was located 1-2, 2-3, and >3 cm from the junction were 125, 28, and 18, respectively. There was a marked difference in the circumferential distribution among the groups defined by distance from that junction. Esophageal mucosal breaks whose distal end were located 0-1 cm from the esophagogastric junction were mainly found on the right anterior wall of the esophagus, while those located 1-2 cm from the junction were mainly found on the right wall, and those located 2-3 and >3 cm from the junction were mainly found on the posterior wall. Conclusion Esophageal mucosal breaks occurring relatively near the esophagogastric junction mainly exist on the right anterior wall, whereas those farther from that junction tend to exist on the posterior wall of the esophagus. The circumferential location of esophageal mucosa highly exposed to refluxed gastric contents changes based on the distance from the esophagogastric junction.
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Affiliation(s)
- Kyoichi Adachi
- Health Center, Shimane Environment and Health Public Corporation, Japan
| | - Takumi Notsu
- Health Center, Shimane Environment and Health Public Corporation, Japan
| | - Tomoko Mishiro
- Health Center, Shimane Environment and Health Public Corporation, Japan
| | - Mayumi Okada
- Second Department of Internal Medicine, Shimane University Faculty of Medicine, Japan
| | - Eiko Okimoto
- Second Department of Internal Medicine, Shimane University Faculty of Medicine, Japan
| | - Yoshikazu Kinoshita
- Second Department of Internal Medicine, Shimane University Faculty of Medicine, Japan
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11
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Everson MA, Ragunath K, Bhandari P, Lovat L, Haidry R. How to Perform a High-Quality Examination in Patients With Barrett's Esophagus. Gastroenterology 2018; 154:1222-1226. [PMID: 29510131 DOI: 10.1053/j.gastro.2018.03.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Martin A Everson
- Division of Surgery & Interventional Science, University College London, London, UK; Department of Gastroenterology, University College Hospital NHS Foundation Trust, London, UK
| | - Krish Ragunath
- Nottingham Digestive Diseases Centre, University of Nottingham and NIHR Biomedical Research Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Pradeep Bhandari
- Department of Gastroenterology, Queen Alexandra Hospital, Hampshire, UK
| | - Laurence Lovat
- Division of Surgery & Interventional Science, University College London, London, UK; Department of Gastroenterology, University College Hospital NHS Foundation Trust, London, UK
| | - Rehan Haidry
- Division of Surgery & Interventional Science, University College London, London, UK; Department of Gastroenterology, University College Hospital NHS Foundation Trust, London, UK.
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12
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Mermelstein J, Chait Mermelstein A, Chait MM. Proton pump inhibitor-refractory gastroesophageal reflux disease: challenges and solutions. Clin Exp Gastroenterol 2018; 11:119-134. [PMID: 29606884 PMCID: PMC5868737 DOI: 10.2147/ceg.s121056] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
A significant percentage of patients with gastroesophageal reflux disease (GERD) will not respond to proton pump inhibitor (PPI) therapy. The causes of PPI-refractory GERD are numerous and diverse, and include adherence, persistent acid, functional disorders, nonacid reflux, and PPI bioavailability. The evaluation should start with a symptom assessment and may progress to imaging, endoscopy, and monitoring of esophageal pH, impedance, and bilirubin. There are a variety of pharmacologic and procedural interventions that should be selected based on the underlying mechanism of PPI failure. Pharmacologic treatments can include antacids, prokinetics, alginates, bile acid binders, reflux inhibitors, and antidepressants. Procedural options include laparoscopic fundoplication and LINX as well as endoscopic procedures, such as transoral incisionless fundoplication and Stretta. Several alternative and complementary treatments of possible benefit also exist.
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Affiliation(s)
- Joseph Mermelstein
- Gasteroenterology and Nutrition Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Alanna Chait Mermelstein
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Maxwell M Chait
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
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13
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Masuda T, Yano F, Omura N, Tsuboi K, Hoshino M, Yamamoto SR, Akimoto S, Kashiwagi H, Yanaga K. Effect of Low-Dose Aspirin on Chronic Acid Reflux Esophagitis in Rats. Dig Dis Sci 2018; 63:72-80. [PMID: 29143196 DOI: 10.1007/s10620-017-4840-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2017] [Accepted: 11/06/2017] [Indexed: 12/23/2022]
Abstract
BACKGROUND Clinical role of low-dose aspirin (LDA) in pathogenesis of gastroesophageal reflux disease is by far controversial. This can be attributed to the paucity of basic research detailing the mechanism of LDA-induced esophageal mucosal injury (EI) on underlying chronic acid reflux esophagitis (RE). AIM The aim of this study was to clarify the effect of LDA on chronic RE in rats. METHODS Esophagitis was induced in 8-week-old male Wistar rats by ligating the border between forestomach and glandular portion with a 2-0 silk tie and covering the duodenum with a small piece of 18-Fr Nélaton catheter. Seventy-eight chronic RE rat models were divided into five treatment groups, consisting of orally administered vehicle (controls), and aspirin doses of 2, 5, 50 or 100 mg/kg once daily for 28 days. EI was assessed by gross area of macroscopic mucosal injury, severity grade of esophagitis and microscopic depth of infiltration by inflammatory cells. RESULTS Area of esophagitis in animals with aspirin dose of 100 mg/kg/day showed a 36.5% increase compared with controls, although it failed to achieve statistical significance (p = 0.812). Additionally, the rate of severe EI was increased in animals with aspirin dose of 100 mg/kg/day as compared with controls (p < 0.05). The grade of severity correlated with the depth of inflammation (r s = 0.492, p < 0.001). CONCLUSIONS Maximal dose aspirin (100 mg/kg/day) contributed in exacerbating preexisting EI. LDA (2 and 5 mg/kg/day), on the other hand, did not affect chronic RE in this model. LDA seems to be safe for use in patients with chronic RE.
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Affiliation(s)
- Takahiro Masuda
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishishinbashi, Minato-ku, Tokyo, 105-8461, Japan.
| | - Fumiaki Yano
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishishinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Nobuo Omura
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishishinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Kazuto Tsuboi
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishishinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Masato Hoshino
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishishinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Se Ryung Yamamoto
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishishinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Shunsuke Akimoto
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishishinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Hideyuki Kashiwagi
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishishinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Katsuhiko Yanaga
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishishinbashi, Minato-ku, Tokyo, 105-8461, Japan
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14
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Vaezi MF, Sifrim D. Assessing Old and New Diagnostic Tests for Gastroesophageal Reflux Disease. Gastroenterology 2018; 154:289-301. [PMID: 28774844 DOI: 10.1053/j.gastro.2017.07.040] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Revised: 07/05/2017] [Accepted: 07/10/2017] [Indexed: 12/13/2022]
Abstract
A detailed critique of objective measurements of gastroesophageal reflux disease (GERD) would improve management of patients suspecting of having reflux, leading to rational selection of treatment and better outcomes. Many diagnostic tests for GERD have been developed over the past decades. We analyze their development, positive- and negative-predictive values, and ability to predict response to treatment. These features are important for development of medical, surgical, and endoscopic therapies for GERD. We discuss the value of available diagnostic tests and review their role in management of patients with persistent reflux symptoms despite adequate medical or surgical treatment. This is becoming a significant health economic problem, due to the widespread use of proton pump inhibitors. GERD is believed to cause nonesophageal symptoms, such as those provoked by ear, nose, throat, or respiratory disorders. We analyze the value of GERD diagnostic tests in evaluation of these troublesome, nonesophageal symptoms.
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Affiliation(s)
- Michael F Vaezi
- Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Daniel Sifrim
- Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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15
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Vakil N, Vieth M, Wernersson B, Wissmar J, Dent J. Diagnosis of gastro-oesophageal reflux disease is enhanced by adding oesophageal histology and excluding epigastric pain. Aliment Pharmacol Ther 2017; 45:1350-1357. [PMID: 28318045 DOI: 10.1111/apt.14028] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Revised: 12/19/2016] [Accepted: 02/14/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND The diagnosis of gastro-oesophageal reflux disease (GERD) in clinical practice is limited by the sensitivity and specificity of symptoms and diagnostic testing. AIM To determine if adding histology as a criterion and excluding patients with epigastric pain enhances the diagnosis for GERD. METHODS Patients with frequent upper gastrointestinal symptoms who had not taken a proton pump inhibitor in the previous 2 months and who had evaluable distal oesophageal biopsies were included (Diamond study: NCT00291746). Epithelial hyperplasia was identified when total epithelial thickness was at least 430 μm. Investigation-based GERD criteria were: presence of erosive oesophagitis, pathological oesophageal acid exposure and/or positive symptom-acid association probability. Symptoms were assessed using the Reflux Disease Questionnaire and a pre-specified checklist. RESULTS Overall, 127 (55%) of the 231 included patients met investigation-based GERD criteria and 195 (84%) met symptom-based criteria. Epithelial hyperplasia was present in 89 individuals, of whom 61 (69%) met investigation-based criteria and 83 (93%) met symptom-based criteria. Adding epithelial hyperplasia as a criterion increased the number of patients diagnosed with GERD on investigation by 28 [12%; number needed to diagnose (NND): 8], to 155 (67%). The proportion of patients with a symptom-based GERD diagnosis who met investigation-based criteria including epithelial hyperplasia was significantly greater when concomitant epigastric pain was absent than when it was present (P < 0.05; NND: 8). CONCLUSIONS Histology increases diagnosis of GERD and should be performed when clinical suspicion is high and endoscopy is negative. Excluding patients with epigastric pain enhances sensitivity for the diagnosis of GERD.
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Affiliation(s)
- N Vakil
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - M Vieth
- Klinikum Bayreuth, Bayreuth, Germany
| | | | - J Wissmar
- AstraZeneca Gothenburg, Mölndal, Sweden
| | - J Dent
- Royal Adelaide Hospital and University of Adelaide, Adelaide, SA, Australia
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16
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Uedo N, Yoshio T, Yoshinaga S, Takeuchi M, Hatta W, Yano T, Tanuma T, Goto O, Takahashi A, Tong D, Lee YY, Nakayama Y, Ichihara S, Gotoda T. Endoscopic gastric mucosal atrophy distinguishes the characteristics of superficial esophagogastric junction adenocarcinoma. Dig Endosc 2017; 29 Suppl 2:26-36. [PMID: 28425653 DOI: 10.1111/den.12849] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Accepted: 02/15/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIM Western studies have suggested two distinct etiologies of esophagogastric junction (EGJ) cancer: Helicobacter pylori-associated atrophic gastritis and non-atrophic gastric mucosa resembling esophageal adenocarcinoma. The present study investigated whether endoscopic gastric mucosal atrophy can distinguish between these two types of EGJ adenocarcinoma. METHODS Data were collected from patients with Siewert type II, T1 EGJ adenocarcinoma who underwent endoscopic or surgical resection at eight Japanese institutions in 2010-2015. Clinicopathological characteristics of EGJ cancers with and without endoscopic gastric mucosal atrophy were compared. EGJ was defined as the lower end of the palisade vein and/or the top of the gastric folds. RESULTS Of the 229 patients identified, 161 had endoscopic gastric mucosal atrophy and 68 did not. The latter group was younger (64 vs 70 years, P = 0.000); had a higher proportion of patients negative for H. pylori (90% vs 47%, P < 0.0001); and had higher rates of gastroesophageal reflux disease symptoms (43% vs 12%, P = 0.017), mucosal breaks (25% vs 15%, P = 0.009), Barrett's esophagus (BE, 78% vs 42%, P < 0.0001), and tumors above the EGJ (81% vs 19%, P < 0.0001) and on the upper-right side (74% vs 38%, P < 0.0001) than the former group. Multivariate analysis showed that H. pylori positivity (odds ratio [OR] = 13.0, P < 0.001), long-segment BE (OR = 0.025, P = 0.033), and longitudinal (OR = 8.6, P = 0.001) and circumferential (OR = 4.7, P = 0.006) tumor locations were independently associated with gastric mucosal atrophy. CONCLUSION Two distinct types of EGJ cancer were identified, with and without endoscopic gastric mucosal atrophy. These types were associated with different tumor locations.
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Affiliation(s)
- Noriya Uedo
- Department of Gastrointestinal Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan
| | - Toshiyuki Yoshio
- Department of Gastroenterology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | | | - Manabu Takeuchi
- Department of Gastroenterology, Nagaoka Red Cross Hospital, Niigata, Japan
| | - Waku Hatta
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Tomonori Yano
- Endoscopy Division, National Cancer Center Hospital East, Kashiwa, Japan
| | - Tokuma Tanuma
- Center for Endoscopy, Teine Keijinkai Hospital, Sapporo, Japan
| | - Osamu Goto
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Akiko Takahashi
- Department of Endoscopy, Saku Central Hospital Advanced Care Center, Saku, Japan
| | - Daniel Tong
- Division of Esophageal and Upper Gastrointestinal Surgery, The University of Hong Kong, Queen Mary Hospital, Hong Kong
| | - Yeong Yeh Lee
- School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, Kelantan, Malaysia
| | - Yoshiko Nakayama
- Department of Pediatrics, Shinshu University School of Medicine, Matsumoto, Japan
| | - Shin Ichihara
- Department of Surgical Pathology, Sapporo Kosei General Hospital, Sapporo, Japan
| | - Takuji Gotoda
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
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17
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Vieth M, Mastracci L, Vakil N, Dent J, Wernersson B, Baldycheva I, Wissmar J, Ruth M, Fiocca R. Epithelial Thickness is a Marker of Gastroesophageal Reflux Disease. Clin Gastroenterol Hepatol 2016; 14:1544-1551.e1. [PMID: 27374007 DOI: 10.1016/j.cgh.2016.06.018] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Revised: 04/22/2016] [Accepted: 06/24/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Histologic criteria have been refined for the diagnosis of gastroesophageal reflux disease (GERD). We aimed to evaluate these criteria for the assessment of GERD and to measure interassessor agreement. METHODS We performed a post hoc analysis of data from the Diamond study (NCT 00291746), conducted in Europe and Canada on adults with frequent upper gastrointestinal symptoms who had not taken a proton pump inhibitor in the previous 2 months. GERD was diagnosed based on the presence of 1 or more of the following: reflux esophagitis, pathologic esophageal acid exposure, and/or positive symptom-acid association probability. Nonerosive reflux disease was defined as the presence of pathologic esophageal acid exposure and/or a positive symptom-acid association probability, but no reflux esophagitis. Biopsies collected from 336 patients from 0.5 cm and 2.0 cm above the Z line were evaluable; they were analyzed independently at pathology centers in Germany and Italy (biopsies from 258 and 195 patients, respectively). The primary outcomes were the accuracy of histologic criteria for the diagnosis of GERD, defined by endoscopy and pH monitoring, and interassessor agreement on histologic criteria. RESULTS At the assessment site for basal cell layer thickness, total epithelial thickness was the best-performing criterion for diagnosis of investigation-defined GERD; it also identified nonerosive reflux disease, reflux esophagitis, and pathologic esophageal acid exposure at 0.5 cm and 2.0 cm above the Z line. Basal cell layer thickness and presence of dilated intercellular spaces did not identify patients with GERD. Among the criteria tested, the best agreement between assessments carried out at the 2 pathology centers was for total epithelial thickness at 0.5 cm and 2.0 cm above the Z line. CONCLUSIONS Based on an analysis of 336 patients with frequent upper gastrointestinal symptoms, total epithelial thickness is a robust histologic marker for GERD.
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Affiliation(s)
| | - Luca Mastracci
- University of Genoa and IRCCS University Hospital S. Marino/IST, Genoa, Italy
| | - Nimish Vakil
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - John Dent
- Royal Adelaide Hospital, University of Adelaide and South Australian Health and Medical Research Institute, Adelaide, SA, Australia
| | | | | | | | - Magnus Ruth
- former employee of AstraZeneca Gothenburg, Mölndal, Sweden
| | - Roberto Fiocca
- University of Genoa and IRCCS University Hospital S. Marino/IST, Genoa, Italy
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18
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Bratlie SO, Edebo A, Casselbrant A, Helander HF, Fändriks L. The renin-angiotensin system in Barrett's esophagus. Scand J Gastroenterol 2016; 51:1037-42. [PMID: 27174460 DOI: 10.1080/00365521.2016.1174881] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Barrett's esophagus (BE) is a risk factor for esophageal adenocarcinoma. In addition to its classical endocrine character known for hemodynamic regulation, the renin-angiotensin system (RAS) can be associated with inflammation, wound healing, and cancer. The aim of this study was to explore a potential expression of the RAS in BE, with or without the presence of dysplasia. MATERIAL AND METHODS Biopsy material was prepared for western blotting and immunohistochemistry. Non-BE patients (controls) were compared with BE patients regarding RAS in the squamous epithelium. In the columnar BE mucosa, RAS expression was studied in patients with and without dysplasia. Key components of the 'classical' RAS were assessed: the angiotensin-converting enzyme (ACE) and the angiotensin II subtype 1 and 2 receptors (AT1R and AT2R). RESULTS The presence of RAS factors was confirmed in the esophageal mucosa of both control and BE patients. ACE protein expression was 48% lower (p = 0.001) whereas AT1R was 45% higher (p = 0.039) in the squamous epithelium of BE patients compared to epithelia from non-BE controls. In the metaplastic intestinal-like epithelium, AT1R expression was 37% higher in BE patients with confirmed dysplasia than in patients without dysplasia (p = 0.009). Immunohistochemistry showed an altered distribution of RAS proteins in BE patients with dysplasia. CONCLUSIONS The differential RAS expression observed may prove to be useful as a biomarker or a pharmaceutical target.
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Affiliation(s)
- Svein Olav Bratlie
- a Department of Gastrosurgical Research and Education , Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital , Gothenburg , Sweden
| | - Anders Edebo
- a Department of Gastrosurgical Research and Education , Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital , Gothenburg , Sweden
| | - Anna Casselbrant
- a Department of Gastrosurgical Research and Education , Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital , Gothenburg , Sweden
| | - Herbert F Helander
- a Department of Gastrosurgical Research and Education , Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital , Gothenburg , Sweden
| | - Lars Fändriks
- a Department of Gastrosurgical Research and Education , Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital , Gothenburg , Sweden
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19
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Omae M, Fujisaki J, Shimizu T, Horiuchi Y, Ishiyama A, Yoshio T, Hirasawa T, Yamamoto Y, Tsuchida T, Igarashi M, Seto Y. Correlation of the location of superficial Barrett's esophageal adenocarcinoma (s-BEA) with the direction of gastroesophageal reflux. Endosc Int Open 2016; 4:E515-20. [PMID: 27227107 PMCID: PMC4874790 DOI: 10.1055/s-0042-101757] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Accepted: 01/18/2016] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Superficial Barrett's esophageal adenocarcinoma (s-BEA) in Barrett's esophagus frequently occurs in the right wall of the esophagus. Our aim was to examine the correlation between the location of s-BEA and the direction of acid and non-acid reflux in patients with Barrett's esophagus. PATIENTS AND METHODS We performed 24-h pH monitoring in 33 s-BEA patients using a pH catheter with eight sensors. One sensor was located at the 6 o'clock position in the lower esophagus and sensors 1 - 8 were arranged counterclockwise at the same level. The catheter was positioned at the same level as the s-BEA. We measured the maximal total duration of acid (MTD-A) and non-acid (MTD-NA) reflux. When the direction of MTD-A and MTD-NA coincided with the location of the s-BEA, the case was defined as coincidental and we calculated the rate of coincidence, and the probability of the rate of coincidence was estimated with 95 % confidence intervals (95 %CI). RESULTS Among the 33 cases of s-BEA examined, the rate of coincidence of both MTD-A and MTD-NA was 24/33 (72.7 %) (95 %CI 0.54 - 0.87). The rate of coincidence of either MTD-A or MTD-NA was 30/33 (90.9 %) (95 %CI 0.76 - 0.98). CONCLUSIONS Our study revealed that the location of s-BEA mostly corresponds to the direction of MTD-A or MTD-NA. Accurate observation of the distribution of acid or non-acid reflux by pH monitoring would aid early detection of s-BEA by endoscopy.
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Affiliation(s)
- Masami Omae
- Department of Gastroenterology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan,Corresponding author Masami Omae, MD Department of GastroenterologyCancer Institute HospitalJapanese Foundation for Cancer Research3-81-6 AriakeKoto-kuTokyo 135-8550Japan+81-3-35200141
| | - Junko Fujisaki
- Department of Gastroenterology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Tomoki Shimizu
- Department of Gastroenterology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yusuke Horiuchi
- Department of Gastroenterology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Akiyoshi Ishiyama
- Department of Gastroenterology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Toshiyuki Yoshio
- Department of Gastroenterology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Toshiaki Hirasawa
- Department of Gastroenterology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yorimasa Yamamoto
- Department of Gastroenterology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Tomohiro Tsuchida
- Department of Gastroenterology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Masahiro Igarashi
- Department of Gastroenterology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yasuyuki Seto
- Department of Gastrointestinal Surgery, The University of Tokyo, Tokyo, Japan
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20
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Okada M, Ishimura N, Shimura S, Mikami H, Okimoto E, Aimi M, Uno G, Oshima N, Yuki T, Ishihara S, Kinoshita Y. Circumferential distribution and location of Mallory-Weiss tears: recent trends. Endosc Int Open 2015; 3:E418-24. [PMID: 26528495 PMCID: PMC4612247 DOI: 10.1055/s-0034-1392367] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Accepted: 05/06/2015] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND AND STUDY AIMS Mallory-Weiss tears (MWTs) are not only a common cause of acute nonvariceal gastrointestinal bleeding but also an iatrogenic adverse event related to endoscopic procedures. However, changes in the clinical characteristics and endoscopic features of MWTs over the past decade have not been reported. The aim of this study was to investigate recent trends in the etiology and endoscopic features of MWTs. PATIENTS AND METHODS We retrospectively reviewed the medical records of patients with a diagnosis of MWT at our university hospital between August 2003 and September 2013. The information regarding etiology, clinical parameters, endoscopic findings, therapeutic interventions, and outcome was reviewed. RESULTS A total of 190 patients with MWTs were evaluated. More than half (n = 100) of the cases occurred during endoscopic procedures; cases related to alcohol consumption were less frequent (n = 13). MWTs were most frequently located in the lesser curvature of the stomach and right lateral wall (2 - to 4-o'clock position) of the esophagus, irrespective of the cause. The condition of more than 90 % of the patients (n = 179) was improved by conservative or endoscopic treatment, whereas 11 patients (5.8 %) required blood transfusion. Risk factors for blood transfusion were a longer laceration (odds ratio [OR] 2.3) and a location extending from the esophagus to the stomach (OR 5.3). CONCLUSIONS MWTs were frequently found on the right lateral wall (2 - to 4-o'clock position) of the esophagus aligned with the lesser curvature of the stomach, irrespective of etiology. Longer lacerations extending from the esophagus to the gastric cardia were associated with an elevated risk for bleeding and requirement for blood transfusion.
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Affiliation(s)
- Mayumi Okada
- Department of Gastroenterology and Hepatology, Shimane University School of Medicine, Izumo, Japan
| | - Norihisa Ishimura
- Department of Gastroenterology and Hepatology, Shimane University School of Medicine, Izumo, Japan,Corresponding author Norihisa Ishimura, MD, PhD Department of Gastroenterology and HepatologyShimane University School of Medicine89-1 Enya-choIzumoShimane 693-8501Japan+81-853-20-2187
| | - Shino Shimura
- Department of Gastroenterology and Hepatology, Shimane University School of Medicine, Izumo, Japan
| | - Hironobu Mikami
- Department of Gastroenterology and Hepatology, Shimane University School of Medicine, Izumo, Japan
| | - Eiko Okimoto
- Department of Gastroenterology and Hepatology, Shimane University School of Medicine, Izumo, Japan
| | - Masahito Aimi
- Department of Gastroenterology and Hepatology, Shimane University School of Medicine, Izumo, Japan
| | - Goichi Uno
- Department of Gastroenterology and Hepatology, Shimane University School of Medicine, Izumo, Japan
| | - Naoki Oshima
- Department of Gastroenterology and Hepatology, Shimane University School of Medicine, Izumo, Japan
| | - Takafumi Yuki
- Department of Gastroenterology and Hepatology, Shimane University School of Medicine, Izumo, Japan
| | - Shunji Ishihara
- Department of Gastroenterology and Hepatology, Shimane University School of Medicine, Izumo, Japan
| | - Yoshikazu Kinoshita
- Department of Gastroenterology and Hepatology, Shimane University School of Medicine, Izumo, Japan
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21
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Allen JI, Katzka D, Robert M, Leontiadis GI. American Gastroenterological Association Institute Technical Review on the Role of Upper Gastrointestinal Biopsy to Evaluate Dyspepsia in the Adult Patient in the Absence of Visible Mucosal Lesions. Gastroenterology 2015; 149:1088-118. [PMID: 26278504 DOI: 10.1053/j.gastro.2015.07.040] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- John I Allen
- Section of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut
| | - David Katzka
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Marie Robert
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut
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22
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Taroni JN, Martyanov V, Huang CC, Mahoney JM, Hirano I, Shetuni B, Yang GY, Brenner D, Jung B, Wood TA, Bhattacharyya S, Almagor O, Lee J, Sirajuddin A, Varga J, Chang RW, Whitfield ML, Hinchcliff M. Molecular characterization of systemic sclerosis esophageal pathology identifies inflammatory and proliferative signatures. Arthritis Res Ther 2015. [PMID: 26220546 PMCID: PMC4518531 DOI: 10.1186/s13075-015-0695-1] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Introduction Esophageal involvement in patients with systemic sclerosis (SSc) is common, but tissue-specific pathological mechanisms are poorly understood. There are no animal scleroderma esophagus models and esophageal smooth muscle cells dedifferentiate in culture prohibiting in vitro studies. Esophageal fibrosis is thought to disrupt smooth muscle function and lead to esophageal dilatation, but autopsy studies demonstrate esophageal smooth muscle atrophy and the absence of fibrosis in the majority of SSc cases. Herein, we perform a detailed characterization of SSc esophageal histopathology and molecular signatures at the level of gene expression. Methods Esophageal biopsies were prospectively obtained during esophagogastroduodenoscopy in 16 consecutive SSc patients and 7 subjects without SSc. Upper and lower esophageal biopsies were evaluated for histopathology and gene expression. Results Individual patient’s upper and lower esophageal biopsies showed nearly identical patterns of gene expression. Similar to skin, inflammatory and proliferative gene expression signatures were identified suggesting that molecular subsets are a universal feature of SSc end-target organ pathology. The inflammatory signature was present in biopsies without high numbers of infiltrating lymphocytes. Molecular classification of esophageal biopsies was independent of SSc skin subtype, serum autoantibodies and esophagitis. Conclusions Proliferative and inflammatory molecular gene expression subsets in tissues from patients with SSc may be a conserved, reproducible component of SSc pathogenesis. The inflammatory signature is observed in biopsies that lack large inflammatory infiltrates suggesting that immune activation is a major driver of SSc esophageal pathogenesis. Electronic supplementary material The online version of this article (doi:10.1186/s13075-015-0695-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jaclyn N Taroni
- Department of Genetics, Geisel School of Medicine at Dartmouth, 1 Rope Ferry Road, Hanover, NH, 03755, USA.
| | - Viktor Martyanov
- Department of Genetics, Geisel School of Medicine at Dartmouth, 1 Rope Ferry Road, Hanover, NH, 03755, USA.
| | - Chiang-Ching Huang
- Zilber School of Public Health, University of Wisconsin, 1240 N 10th Street, Milwaukee, WI, 53205, USA.
| | - J Matthew Mahoney
- Department of Neurological Sciences, College of Medicine, University of Vermont, 89 Beaumont Avenue, Burlington, VT, 05405, USA.
| | - Ikuo Hirano
- Department of Medicine, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, 676 N. Saint Clair Street, Suite 1400, Chicago, IL, 60611, USA.
| | - Brandon Shetuni
- Department of Pathology, Northwestern University Feinberg School of Medicine, 303 E. Chicago Avenue, Ward- 3-140, Chicago, IL, 60611, USA.
| | - Guang-Yu Yang
- Department of Pathology, Northwestern University Feinberg School of Medicine, 303 E. Chicago Avenue, Ward- 3-140, Chicago, IL, 60611, USA.
| | - Darren Brenner
- Department of Medicine, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, 676 N. Saint Clair Street, Suite 1400, Chicago, IL, 60611, USA.
| | - Barbara Jung
- Department of Medicine, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, 676 N. Saint Clair Street, Suite 1400, Chicago, IL, 60611, USA. .,Department of Medicine, Division of Gastroenterology, University of Illinois Chicago, 808 S Wood Street, Chicago, Illinois, 60612, USA.
| | - Tammara A Wood
- Department of Genetics, Geisel School of Medicine at Dartmouth, 1 Rope Ferry Road, Hanover, NH, 03755, USA.
| | - Swati Bhattacharyya
- Department of Medicine, Division of Rheumatology, Northwestern University Feinberg School of Medicine, 240 E. Huron Street, Suite M300, Chicago, IL, 60611, USA.
| | - Orit Almagor
- Department of Medicine, Division of Rheumatology, Northwestern University Feinberg School of Medicine, 240 E. Huron Street, Suite M300, Chicago, IL, 60611, USA.
| | - Jungwha Lee
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, 680 N. Lake Shore Drive, Suite 1400, Chicago, IL, 60611, USA. .,Institute for Public Health and Medicine, Northwestern University, 633 N. St. Clair Street, 18th floor, Chicago, IL, 60611, USA.
| | - Arlene Sirajuddin
- Department of Radiology, Northwestern University Feinberg School of Medicine, 676 N. St. Clair Street, Chicago, IL, 60611, USA.
| | - John Varga
- Department of Medicine, Division of Rheumatology, Northwestern University Feinberg School of Medicine, 240 E. Huron Street, Suite M300, Chicago, IL, 60611, USA.
| | - Rowland W Chang
- Department of Medicine, Division of Rheumatology, Northwestern University Feinberg School of Medicine, 240 E. Huron Street, Suite M300, Chicago, IL, 60611, USA. .,Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, 680 N. Lake Shore Drive, Suite 1400, Chicago, IL, 60611, USA. .,Institute for Public Health and Medicine, Northwestern University, 633 N. St. Clair Street, 18th floor, Chicago, IL, 60611, USA. .,Department of Physical Medicine and Rehabilitation, Northwestern University Feinberg School of Medicine, 710 N. Lake Shore Drive, Chicago, IL, 60611, USA.
| | - Michael L Whitfield
- Department of Genetics, Geisel School of Medicine at Dartmouth, 1 Rope Ferry Road, Hanover, NH, 03755, USA.
| | - Monique Hinchcliff
- Department of Medicine, Division of Rheumatology, Northwestern University Feinberg School of Medicine, 240 E. Huron Street, Suite M300, Chicago, IL, 60611, USA. .,Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, 680 N. Lake Shore Drive, Suite 1400, Chicago, IL, 60611, USA. .,Institute for Public Health and Medicine, Northwestern University, 633 N. St. Clair Street, 18th floor, Chicago, IL, 60611, USA.
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Predictors of Progression to High-Grade Dysplasia or Adenocarcinoma in Barrett's Esophagus. Gastroenterol Clin North Am 2015; 44:299-315. [PMID: 26021196 PMCID: PMC4449455 DOI: 10.1016/j.gtc.2015.02.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The prevalence of esophageal adenocarcinoma is increasing dramatically. Barrett's esophagus remains the most well-established risk factor for the development of esophageal adenocarcinoma. There are multiple clinical, endoscopic, and pathologic factors that increase the risk of neoplastic progression to high-grade dysplasia or esophageal adenocarcinoma in Barrett's esophagus. This article reviews both risk and protective factors for neoplastic progression in patients with Barrett's esophagus.
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Triantos C, Koukias N, Karamanolis G, Thomopoulos K. Changes in the esophageal mucosa of patients with non erosive reflux disease: How far have we gone? World J Gastroenterol 2015; 21:5762-5767. [PMID: 26019440 PMCID: PMC4438010 DOI: 10.3748/wjg.v21.i19.5762] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2014] [Revised: 03/13/2015] [Accepted: 04/17/2015] [Indexed: 02/06/2023] Open
Abstract
The normal esophageal mucosa creates a protective epithelial barrier that constrains the acidic reflux in the esophageal lumen. Microscopic findings and functional studies indicate that this barrier might be impaired in patients with non erosive reflux disease (NERD) but not in patients with functional heartburn (FH). Whereas endoscopy and pH monitoring are the most important diagnostic tools in the diagnosis of NERD, recent studies suggest that esophageal biopsies might have a complementary role. Particularly in the differential diagnosis between NERD and FH, the application of histological severity scores showed very promising results. Further evaluation of the scores could lead to routine application of histology in specific NERD populations.
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25
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Ishimura N, Okada M, Mikami H, Okimoto E, Fukuda N, Uno G, Aimi M, Oshima N, Ishihara S, Kinoshita Y. Pathophysiology of Barrett's esophagus-associated neoplasia: circumferential spatial predilection. Digestion 2015; 89:291-8. [PMID: 25059643 DOI: 10.1159/000365123] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The prevalence rates of Barrett's esophagus (BE) and esophageal adenocarcinoma (EAC) arising from BE show striking geographic patterns as they are much more common in Western as compared with Asian countries. However, recent epidemiological studies indicate that the number of patients with BE and EAC are gradually increasing in Asia including Japan, corresponding to the increase in prevalence of gastroesophageal reflux disease (GERD). Because the prognosis of patients with advanced-stage EAC remains poor, early detection of neoplastic lesion in those with BE has led to recent interest in effective treatment. Several promising studies have revealed that early neoplasia in BE is mainly located in the right anterior wall of the distal esophagus. Interestingly, this endoscopic characteristic has been found in both Western and Japanese populations. Potential pathophysiologic explanations underlying the circumferential distribution of neoplasia in BE include a nonuniform asymmetric distribution of esophageal acid exposure, with a tendency toward mucosal acid-related injury on the right side of the esophageal wall in patients with GERD, and the functional structure of the lower esophageal sphincter. Findings of the present study should improve lesion detection and aid in developing a target biopsy protocol for surveillance of BE.
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Affiliation(s)
- Norihisa Ishimura
- Department of Gastroenterology and Hepatology, Shimane University School of Medicine, Izumo, Japan
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26
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Ates F, Yuksel ES, Higginbotham T, Slaughter JC, Mabary J, Kavitt RT, Garrett CG, Francis D, Vaezi MF. Mucosal impedance discriminates GERD from non-GERD conditions. Gastroenterology 2015; 148:334-43. [PMID: 25448923 DOI: 10.1053/j.gastro.2014.10.010] [Citation(s) in RCA: 112] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Revised: 10/09/2014] [Accepted: 10/14/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Current diagnostic tests for gastroesophageal reflux disease (GERD) are suboptimal and do not accurately and reliably measure chronicity of reflux. A minimally invasive device has been developed to assess esophageal mucosal impedance (MI) as a marker of chronic reflux. We performed a prospective longitudinal study to investigate MI patterns in patients with GERD and common nonreflux conditions, to assess MI patterns before and after treatment with proton pump inhibitors and to compare the performance of MI and wireless pH tests. METHODS We evaluated MI in 61 patients with erosive esophagitis, 81 with nonerosive but pH-abnormal GERD, 93 without GERD, 18 with achalasia, and 15 with eosinophilic esophagitis. MI was measured at the site of esophagitis and at 2, 5, and 10 cm above the squamocolumnar junction in all participants. MI was measured before and after acid suppressive therapy, and findings were compared with those from wireless pH monitoring. RESULTS MI values were significantly lower in patients with GERD (erosive esophagitis or nonerosive but pH-abnormal GERD) or eosinophilic esophagitis than in patients without GERD or patients with achalasia (P < .001). The pattern of MI in patients with GERD differed from that in patients without GERD or patients with eosinophilic esophagitis; patients with GERD had low MI closer to the squamocolumnar junction, and values increased axially along the esophagus. These patterns normalized with acid suppressive therapy. MI patterns identified patients with esophagitis with higher levels of specificity (95%) and positive predictive values (96%) than wireless pH monitoring (64% and 40%, respectively). CONCLUSIONS Based on a prospective study using a prototype device, measurements of MI detect GERD with higher levels of specificity and positive predictive values than wireless pH monitoring. Clinical Trials.gov, Number: NCT01556919.
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Affiliation(s)
- Fehmi Ates
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt Medical Center, Nashville, Tennessee
| | - Elif Saritas Yuksel
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt Medical Center, Nashville, Tennessee
| | - Tina Higginbotham
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt Medical Center, Nashville, Tennessee
| | - James C Slaughter
- Department of Biostatistics, Vanderbilt Medical Center, Nashville, Tennessee
| | | | - Robert T Kavitt
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt Medical Center, Nashville, Tennessee
| | - C Gaelyn Garrett
- Vanderbilt Voice Center, Vanderbilt Institute for Medicine & Public Health, Nashville, Tennessee
| | - David Francis
- Vanderbilt Voice Center, Vanderbilt Institute for Medicine & Public Health, Nashville, Tennessee; Center for Surgical Quality and Outcomes Research, Vanderbilt Institute for Medicine & Public Health, Nashville, Tennessee
| | - Michael F Vaezi
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt Medical Center, Nashville, Tennessee.
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Abstract
Gastroesophageal reflux disease (GERD) is one of the most common digestive diseases in the Western world, with typical symptoms, such as heartburn, regurgitation, or retrosternal pain, reported by 15% to 20% of the general population. The pathophysiology of GERD is multifactorial. Our understanding of these factors has significantly improved in recent years, with increased understanding of the acid pocket and hiatal hernia and how these factors interact. Although our insight has significantly increased over the past years, more studies are required to better understand symptom generation in GERD, especially in patients with therapy-resistant symptoms.
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Affiliation(s)
- Guy E Boeckxstaens
- Department of Gastroenterology, Translational Research Center for Gastrointestinal Disorders (TARGID), University Hospital of Leuven, University of Leuven, Herestraat 49, Leuven 3000, Belgium.
| | - Wout O Rohof
- Department of Gastroenterology and Hepatology, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
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28
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Björkman E, Edebo A, Fändriks L, Casselbrant A. Angiotensin IV and the human esophageal mucosa: An exploratory study in healthy subjects and gastroesophageal reflux disease patients. J Renin Angiotensin Aldosterone Syst 2014; 16:570-7. [PMID: 24452037 DOI: 10.1177/1470320313512389] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Accepted: 09/07/2013] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION The human esophageal mucosa expresses various components of the renin-angiotensin system (RAS), e.g. the main effector peptide angiotensin II (AngII). The aim of this study was to investigate the esophageal presence of angiotensin III (AngIII) and angiotensin IV (AngIV) forming enzymes and the AngIV receptor (AT4R). The aim was also to study the actions of AngIV and to look for aberrations in patients with gastroesophageal reflux disease (GERD). MATERIALS AND METHODS Esophageal biopsies were collected from healthy volunteers (n: 19) and individuals with erosive reflux disease (n: 14). Gene transcripts and protein expression of aminopeptidase A, -B and -M, and the AT4R were investigated by reverse transcriptase polymerase chain reaction (rt-PCR), western blot (WB) and immunohistochemistry (IHC). The functional impact of AngIV was examined in an Ussing chamber. RESULTS Aminopeptidase A, -B and -M and the AT4R were expressed in the esophageal epithelium. The AT4R was less prominent in certain areas in the mucosa of reflux patients. AngIV influenced the esophageal epithelial ion transport. The impact was lower in patients with GERD. CONCLUSION The AT4R and formation enzymes of AngIII and AngIV are present in the human esophageal epithelium. Moreover, the present results suggest that AngIV exert regulatory impact on the epithelium and that RAS is involved in mucosal aberrations associated with GERD.
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Affiliation(s)
- Eleonora Björkman
- Department of Gastrosurgical Research and Education, University of Gothenburg, Sweden
| | - Anders Edebo
- Department of Gastrosurgical Research and Education, University of Gothenburg, Sweden
| | - Lars Fändriks
- Department of Gastrosurgical Research and Education, University of Gothenburg, Sweden
| | - Anna Casselbrant
- Department of Gastrosurgical Research and Education, University of Gothenburg, Sweden
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29
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Gastroesophageal acid reflux mainly occurs on the right side of the esophagus. Gastrointest Endosc 2014; 79:180-1. [PMID: 24342594 DOI: 10.1016/j.gie.2013.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Accepted: 08/02/2013] [Indexed: 02/08/2023]
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30
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Johannessen R, Skogaker N, Halgunset J, Petersen H, Kleveland PM. A standardized method for measuring intercellular spaces in esophageal biopsies in patients with suspected gastroesophageal reflux disease (the intercellular space ratio). Scand J Gastroenterol 2013; 48:1235-41. [PMID: 24079906 DOI: 10.3109/00365521.2013.838996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Dilated intercellular space (DIS) in esophageal biopsies is regarded as a possible early sign of mucosal injury in gastroesophageal reflux disease (GERD). This study presents a standardized approach of intercellular space measurement. MATERIAL AND METHODS Distal and proximal esophageal biopsies were taken from 19 patients with suspected GERD, and examined with TEM. A grid containing 150 line-crossing points was applied upon each photomicrograph. The number of points falling on the intercellular space was divided by the total number of points of the grid, thereby creating a ratio called the intercellular space ratio (ISR). The ISR method was validated with regard to intra- and interobserver agreement, and was compared to a widely used method for measuring intercellular space diameter developed by Tobey et al. (Tobey NA, Carson JL, Alkiek RA, Orlando RC. Dilated intercellular spaces: a morphological feature of acid reflux-damaged human esophageal epithelium. Gastroenterology 1996;111(5):1200-1205). The ISR was also compared to other markers for GERD. Results. Pearson's correlation coefficients for intra- and interobserver agreement were 0.91 (p < 0.001) and 0.82 (p < 0.001), respectively. The Pearson's correlation coefficient between the ISR and the intercellular space diameter according to Tobey et al., measured in the same micrographs, was 0.32 (p < 0.001). The proximal ISR correlated significantly with the distal ISR (Spearman's rho = 0.57, p = 0.010), and with heartburn symptom score (Spearman's rho = 0.50, p = 0.028). CONCLUSIONS The ISR showed a high intraobserver and interobserver agreement. It also displayed good external validity when compared to other markers for gastroesophageal reflux. A rather poor correlation was however found between the ISR and the intercellular space diameter measured as described by Tobey et al.
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Affiliation(s)
- Rune Johannessen
- Unit for Gastroenterology, Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology , Trondheim , Norway
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31
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Björkman EVC, Edebo A, Oltean M, Casselbrant A. Esophageal barrier function and tight junction expression in healthy subjects and patients with gastroesophageal reflux disease: functionality of esophageal mucosa exposed to bile salt and trypsin in vitro. Scand J Gastroenterol 2013; 48:1118-26. [PMID: 24047393 DOI: 10.3109/00365521.2013.828772] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS. Gastroesophageal reflux disease (GERD) is associated with impaired epithelial barrier function. However, the influence of acid and/or bile acids on human esophageal epithelial barrier function and the tight junction (TJ) proteins has not been fully elucidated. The aim of the study is to investigate the esophageal barrier function and TJ expression in healthy subjects and patients with GERD. The functionality of esophageal mucosa exposed to bile salt deoxycholic acid (DCA) and trypsin has been studied in vitro. MATERIAL AND METHODS. Endoscopic biopsies from healthy controls and patients with GERD-related symptom with endoscopic erosive signs, as well as esophageal mucosa taken from patients undergoing esophagectomy were evaluated in Ussing chambers and by western blot and immunohistochemistry. RESULTS. The esophageal epithelium from GERD patients had lower electrical resistance and higher epithelial currents than controls. Claudin-1 and -4 were significantly decreased in GERD patients. The bile salt DCA in the low concentration of 1.5 mM and trypsin increased the resistance and claudin-1 expression, while the higher concentration of 2.5 mM DCA and trypsin decreased the resistance and the claudin-3, -4 and E-cadherin expressions. CONCLUSION. In addition to acidic reflux, duodenal reflux components, such as bile salts and trypsin, have the potential to disrupt the esophageal barrier function, partly by modulating the TJ proteins. However, the expression of TJ is dependent on both the refluxed material as well as the concentration of the bile salt.
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Affiliation(s)
- Eleonora Victoria Charlotta Björkman
- Department of Gastrosurgical Research and Education, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg , Gothenburg , Sweden
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Enestvedt BK, Lugo R, Guarner-Argente C, Shah P, Falk GW, Furth E, Ginsberg GG. Location, location, location: does early cancer in Barrett's esophagus have a preference? Gastrointest Endosc 2013; 78:462-7. [PMID: 23622975 DOI: 10.1016/j.gie.2013.03.167] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Accepted: 03/07/2013] [Indexed: 12/13/2022]
Abstract
BACKGROUND Early cancer (high-grade dysplasia [HGD] and intramucosal carcinoma [ImCa]) associated with Barrett's esophagus (BE) may have a circumferential spatial predilection. OBJECTIVE To describe the esophageal circumferential location of early cancer in BE. DESIGN AND SETTING Retrospective study, single tertiary referral center. PATIENTS AND INTERVENTION One hundred nineteen patients were referred for endoscopic eradication therapy for early cancer associated with BE. Endoscopic images and reports and pathology were reviewed. MAIN OUTCOME MEASUREMENTS Circumferential location designation of early cancer in BE by using a clock-face orientation. RESULTS One hundred nineteen of 131 patients referred for endoscopic eradication therapy had a location designation for their advanced histology (91.9%). There were a total of 57 patients (47.9%) with HGD and 62 patients (52.1%) with ImCa. There was a significantly higher rate of early cancer (HGD or ImCa) in the right hemisphere (12 to 6 o'clock location) compared with the left hemisphere (84.9% vs 15.1%, P < .0001). The highest percentage of early cancer was found in the 12 to 3 o'clock quadrant (64.7%); 71.9% of HGD and 58.1% of ImCa lesions were located in the 12 to 3 o'clock quadrant. LIMITATIONS Retrospective design, single center. CONCLUSIONS Early cancer associated with BE is far more commonly found in the right hemisphere of the esophagus (12 to 6 o'clock) with the highest rate in the 12 to 3 o'clock quadrant. These findings support enhanced scrutiny of the right hemisphere of the esophagus during surveillance and endoscopic treatment of patients with BE.
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Affiliation(s)
- Brintha K Enestvedt
- Department of Medicine, Division of Gastroenterology, Temple University School of Medicine, Philadelphia, Pennsylvania, USA
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Liu CC, Lee JW, Liu TT, Yi CH, Chen CL. Relevance of ultrastructural alterations of intercellular junction morphology in inflamed human esophagus. J Neurogastroenterol Motil 2013; 19:324-31. [PMID: 23875099 PMCID: PMC3714410 DOI: 10.5056/jnm.2013.19.3.324] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Revised: 04/30/2013] [Accepted: 05/03/2013] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND/AIMS Detailed characterization of the ultrastructural morphology of intercellular space in gastroesophageal reflux disease has not been fully studied. We aimed to investigate whether subtle alteration in intercellular space structure and tight junction proteins might differ among patients with gastroesophageal reflux disease. METHODS Esophageal biopsies at 5 cm above the gastroesophageal junction were obtained from 6 asymptomatic controls, 10 patients with reflux symptoms but without erosions, and 18 patients with erosions. The biopsies were morphologically evaluated by transmission electron microscopy, and by using immunohistochemistry for tight junction proteins (claudin-1 and claudin-2 proteins). RESULTS The expressions of tight junction proteins did not differ between asymptomatic controls and gastroesophageal reflux disease patients. In patients with gastroesophageal reflux disease, altered desmosomal junction morphology was only found in upper stratified squamous epithelium. Dilated intercellular space occurred only in upper stratified squamous epithelium and in patients with erosive esophagitis. CONCLUSIONS This study suggests that dilated intercellular space may not be uniformly present inside the esophageal mucosa and predominantly it is located in upper squamous epithelium. Presence of desmosomal junction alterations is associated with increased severity of gastroesophageal reflux disease. Besides dilated intercellular space, subtle changes in ultrastructural morphology of intercellular space allow better identification of inflamed esophageal mucosa relevant to acid reflux.
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Affiliation(s)
- Chia-Chin Liu
- Department of Life Sciences, Tzu Chi University, Hualien, Taiwan
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Krugmann J, Neumann H, Vieth M, Armstrong D. What is the role of endoscopy and oesophageal biopsies in the management of GERD? Best Pract Res Clin Gastroenterol 2013; 27:373-85. [PMID: 23998976 DOI: 10.1016/j.bpg.2013.06.010] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2013] [Revised: 06/21/2013] [Accepted: 06/28/2013] [Indexed: 01/31/2023]
Abstract
Gastroesophageal reflux disease (GERD) is a diagnosis applicable to "all individuals who are exposed to the risk of physical complications from gastroesophageal reflux, or who experience clinically significant impairment of health related well being (quality of life) due to reflux related symptoms, after adequate reassurance of the benign nature of their symptoms". It remains, predominantly, a symptom-based diagnosis, confirmed clinically by a response to acid suppression therapy although it is accompanied by demonstrable increases in acid exposure on esophageal pH-metry and by endoscopic and histological changes. Standard white light endoscopy permits diagnosis of erosive reflux disease (ERD) which, if present, should be graded for severity using the Los Angeles classification system. However, the role of endoscopy in clinical practice is, primarily, to evaluate patients with persistent symptoms, despite medical therapy, or to investigate alarm features and exclude complications such as Barrett' oesophagus which should be assessed using the Prague C & M criteria. Newer endoscopic techniques allow detection of 'minimal change' GERD lesions and Barrett's oesophagus-associated dysplastic or neoplastic lesions; however, none of the newer techniques has been validated for routine clinical practice. There is an increasing recognition that histology in GERD may provide useful diagnostic information, in part to exclude other lesions, such as eosinophilic oesophagitis, intestinal metaplasia and dysplasia or malignancy and, in part, to identify changes, such as basal cell hyperplasia, papillary elongation and, most recently, dilated intercellular spaces, that are consistent with GERD. However, more widespread incorporation of histology into the clinical management of GERD will require a standardized biopsy protocol and efforts to minimise interobserver differences in the identification of GERD-related histological changes.
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Affiliation(s)
- Jens Krugmann
- Institute of Pathology, Klinikum Bayreuth, Preuschwitzerstr. 101, 95445 Bayreuth, Germany
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Cassani L, Sumner E, Slaughter JC, Yachimski P. Directional distribution of neoplasia in Barrett's esophagus is not influenced by distance from the gastroesophageal junction. Gastrointest Endosc 2013; 77:877-82. [PMID: 23528657 DOI: 10.1016/j.gie.2013.01.026] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2012] [Accepted: 01/18/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND Accurate endoscopic detection and staging are critical for appropriate management of Barrett's esophagus (BE)-associated neoplasia. Prior investigation has demonstrated that the distribution of endoscopically detectable early neoplasia is not uniform but instead favors specific directional distributions within a short BE segment; however, it is unknown whether the directional distribution of neoplasia differs with increasing distance from the gastroesophageal junction, including in patients with long-segment BE. OBJECTIVE To identify whether directional distribution of BE-associated neoplasia is influenced by distance from the gastroesophageal junction. DESIGN Retrospective cohort study. SETTING Tertiary-care referral center. PATIENTS Patients with either short-segment or long-segment BE undergoing EMR. INTERVENTION EMR. MAIN OUTCOME MEASUREMENTS Directional distribution of BE-associated neoplasia stratified by distance from gastroesophageal junction. RESULTS EMR was performed on 60 lesions meeting study criteria during the specified time period. Pathology demonstrated low-grade dysplasia in 22% (13/60), high-grade dysplasia in 38% (23/60), intramucosal (T1a) adenocarcinoma in 23% (14/60), and invasive (≥ T1b) adenocarcinoma in 17% (10/60). Directional distribution of lesions was not uniform (P < .001), with 62% of lesions (37/60) located between the 1 o'clock and 5 o'clock positions. When circular statistics methodology was used, there was no difference in the directional distribution of neoplastic lesions located within 3 cm of the gastroesophageal junction compared with ≥ 3 cm from the gastroesophageal junction. LIMITATIONS Single-center study may limit external validity. CONCLUSION The directional distribution of neoplastic foci within a BE segment is not influenced by distance of the lesion from the gastroesophageal junction. Mucosa between the 1 o'clock and 5 o'clock locations merits careful attention and endoscopic inspection in individuals with both short-segment BE and long-segment BE.
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Affiliation(s)
- Lisa Cassani
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee 37232-5280, USA
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Björkman E, Edebo A, Casselbrant A, Helander HF, Bratlie SO, Vieth M, Fändriks L. The renin-angiotensin system in the esophageal mucosa of healthy subjects and patients with reflux disease. Scand J Gastroenterol 2013; 48:147-59. [PMID: 23270416 DOI: 10.3109/00365521.2012.749510] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Components of the renin-angiotensin system (RAS) were recently discovered in the esophagus, which could be of interest in relation to gastroesophageal reflux disease (GERD). The present study was undertaken to confirm and further investigate the expression of RAS in healthy and refluxed exposed human esophageal mucosae. METHODS Esophageal biopsies were obtained from healthy subjects (n = 34) and individuals with erosive reflux disease (ERD, n = 28). Evaluation of general morphology and histological signs of reflux as well as investigation of gene transcript, protein expression and localization of various RAS components using RT-PCR, ELISA, western blot and immunohistochemistry were performed. Physiological effects of the AT2R were investigated in Ussing chamber experiments. RESULTS The study confirmed histological signs of reflux in ERD and expression of ACE, AT1R, AT2R and CatD in all examined specimens. In addition, the main effector peptide AngII, the pro-hormone AGT, the Mas receptor and the angiotensin-forming enzymes renin, CMA, CatG and NEP were present. Individuals with reflux disease had higher transcription activity of ACE and AT1R, increased protein levels of AT2R and lower levels of MasR. AT2R stimulation increased the ion currents in healthy epithelium, whereas epithelium from individuals with reflux disease exhibited no significant response. CONCLUSIONS The study demonstrated that a local RAS is present in the human esophageal epithelium. Some RAS components were significantly altered in individuals diagnosed with ERD suggesting involvement in the pathophysiology of GERD.
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Affiliation(s)
- Eleonora Björkman
- Department of Gastrosurgical Research and Education, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
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Ohara S, Furuta K, Adachi K, Shimura S, Fukazawa K, Aimi M, Okamoto E, Komazawa Y, Kinoshita Y. Radially asymmetric gastroesophageal acid reflux in the distal esophagus: examinations with novel pH sensor catheter equipped with 8 pH sensors. J Gastroenterol 2012; 47:1221-7. [PMID: 22526277 DOI: 10.1007/s00535-012-0595-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2011] [Accepted: 03/23/2012] [Indexed: 02/04/2023]
Abstract
BACKGROUND Esophageal mucosal breaks in patients with Los Angeles (LA) grade A or B esophagitis are mainly found in the right anterior wall of the distal esophagus. The aim of this study was to reveal radial acid exposure in the distal esophagus and determine whether radial asymmetry of acid exposure is a possible cause of radially asymmetric distribution of the lesions. METHODS We developed a novel pH sensor catheter using a polyvinyl chloride catheter equipped with 8 antimony pH sensors radially arrayed at the same level. Four healthy volunteers, 5 patients with non-erosive reflux disease (NERD), and 10 with LA grade A or B esophagitis were enrolled. The sensors were set 2 cm above the upper limit of the lower esophageal sphincter, and post-prandial gastroesophageal acid reflux was monitored for 3 h with the subjects in a sitting position. RESULTS We successfully examined radial acid exposure in the distal esophagus in all subjects using our novel pH sensor catheter. Radial variations of acid exposure in the distal esophagus were not observed in the healthy subjects. In contrast, the patients with NERD and those with reflux esophagitis had radial asymmetric acid exposure that was predominant on the right wall of the distal esophagus. In the majority of patients with reflux esophagitis, the directions of longer acid exposure coincided with the locations of mucosal breaks. CONCLUSIONS Radial acid exposure could be examined using our novel 8-channel pH sensor catheter. We found that the directions of longer acid exposure were associated with the locations of mucosal breaks.
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Affiliation(s)
- Shunji Ohara
- Department of Gastroenterology and Hepatology, Shimane University School of Medicine, 89-1 Enya-cho, Izumo, Shimane 693-8501, Japan
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Saritas Yuksel E, Higginbotham T, Slaughter JC, Mabary J, Kavitt RT, Garrett CG, Vaezi MF. Use of direct, endoscopic-guided measurements of mucosal impedance in diagnosis of gastroesophageal reflux disease. Clin Gastroenterol Hepatol 2012; 10:1110-6. [PMID: 22642956 DOI: 10.1016/j.cgh.2012.05.018] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2012] [Revised: 05/08/2012] [Accepted: 05/10/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Diagnostic tests for gastroesophageal reflux disease (GERD) are constrained because measurements are made at a single time point, so the long-term effects on the mucosa cannot be determined. We developed a minimally invasive system to assess changes in esophageal mucosal impedance (MI), a marker of reflux. We measured the extent of changes in MI along the esophagus and show that the device to assess MI can be used to diagnose patients with GERD. METHODS A single-channel MI catheter composed of a unique sensor array was designed to easily traverse the working channel of an upper endoscope. We performed a prospective longitudinal study of patients with erosive esophagitis (n = 19), nonerosive but pH-positive GERD (n = 23), and those without GERD (n = 27). MI was measured at the site of esophagitis as well as 2, 5, and 10 cm above the squamocolumnar junction. The MI values were compared among groups, at different levels along the esophageal axis. RESULTS Median MI values were significantly lower at the site of erosive mucosa (811 Ω; range, 621-1272 Ω) than other nonerosive regions (3723 Ω; range, 2421-4671 Ω; P = .001), and were significantly lower at 2 cm above the squamocolumnar junction in patients with GERD (2096 Ω; range, 1415-2808 Ω), compared with those without GERD (3607 Ω; range, 1973-4238 Ω; P = .008). There was a significant and graded increase in MI along the axis of the distal to proximal esophagus in patients with GERD that was not observed in individuals without reflux (P = .004). CONCLUSIONS Measurements of MI along the esophagus can be used to identify patients with GERD. ClinicalTrials.gov, number NCT01194323.
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Affiliation(s)
- Elif Saritas Yuksel
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt Medical Center, Nashville, TN 37232-5280, USA
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Kurien M, Evans KE, Hopper AD, Hale MF, Cross SS, Sanders DS. Duodenal bulb biopsies for diagnosing adult celiac disease: is there an optimal biopsy site? Gastrointest Endosc 2012; 75:1190-6. [PMID: 22624810 DOI: 10.1016/j.gie.2012.02.025] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2011] [Accepted: 02/13/2012] [Indexed: 12/18/2022]
Abstract
BACKGROUND Recent studies highlight the role of duodenal bulb biopsy in the diagnosis of celiac disease. OBJECTIVE To determine whether a targeted duodenal bulb biopsy in addition to distal duodenal biopsies is the optimal strategy to identify villous atrophy. DESIGN Prospective cohort study. SETTING Tertiary-care referral center. PATIENTS Seventy-seven patients undergoing clinically indicated EGD with duodenal biopsies were recruited. Of these, 28 had newly diagnosed celiac disease and 49 were controls. INTERVENTIONS At endoscopy, 8 duodenal biopsy specimens were taken: 4 from the second part of the duodenum and 4 quadrantically from the bulb (at the 3-, 6-, 9-, and 12-o'clock positions). MAIN OUTCOME MEASUREMENTS Increasing the diagnostic yield and detection of the most severe villous atrophy in celiac disease with the addition of a targeted duodenal bulb biopsy. RESULTS The most severe degree of villous atrophy was detected when distal duodenal biopsy specimens were taken in addition to a duodenal bulb biopsy specimen from either the 9- or 12-o'clock position (96.4% sensitivity; 95% CI, 79.7%-100%). The difference between the 12-o'clock position biopsy and the 3-o'clock position biopsy in detecting the most severe villous atrophy was 92% (24/26) versus 65% (17/26) (P = .02). LIMITATIONS Small sample and study performed in a tertiary referral center. CONCLUSIONS This study demonstrates the patchy appearance of villous atrophy that occurs within the duodenum. A targeted duodenal bulb biopsy from either the 9- or 12-o'clock position in addition to distal duodenal biopsies may improve diagnostic yields by detecting the most severe villous atrophy within the duodenum.
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Affiliation(s)
- Matthew Kurien
- Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
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Kariyawasam VC, Bourke MJ, Hourigan LF, Lim G, Moss A, Williams SJ, Fanning SB, Chung AM, Byth K. Circumferential location predicts the risk of high-grade dysplasia and early adenocarcinoma in short-segment Barrett's esophagus. Gastrointest Endosc 2012; 75:938-44. [PMID: 22381529 DOI: 10.1016/j.gie.2011.12.025] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2011] [Accepted: 12/19/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND Whether early Barrett's neoplasia has a predilection for particular spatial locations in shorter segment disease is currently unknown. Anatomic factors may play a role in lesion location because of differing levels of mucosal acid exposure. OBJECTIVE To identify high-risk lesion locations, which has important implications for surveillance strategies. DESIGN We interrogated a prospectively maintained database of patients who underwent endoscopic resection (ER) for Barrett's neoplasia at 2 Australian tertiary centers. Lesions targeted for ER were characterized and their location in the distal esophagus was noted as on a clock face. A Z test of proportions was used to test for deviation from uniformity in the distribution of lesions. SETTING Two Australian tertiary centers. PATIENTS Patients who underwent ER for Barrett's neoplasia. MAIN OUTCOME MEASUREMENTS Lesion location in the distal oesophagus, resected specimen histology. RESULTS A total of 146 consecutive patients had ER for biopsy-proven high-grade dysplasia or esophageal adenocarcinoma. A total of 75 patients had Barrett's segment length of 5 cm or less and a visible lesion. Five patients had 2 visible lesions giving a total of 80 lesions. ER of 66 lesions (82.5%) led to the identification of advanced pathology: 37 high-grade dysplasia (46%), 24 mucosal adenocarcinoma (30%), 5 submucosal adenocarcinoma (6%). Of a total of 80 lesions, 43 (53.8%) (95% CI, 42.9%-64.7%) were centered within the 2- to 5-o'clock arc, comprising 25% of the circumference. This area also accounted for 36 (54.5%) of the 66 lesions with advanced histology (95% CI, 42.5%-66.5%). All confidence intervals lie wholly above the 25% expected in a uniform circular distribution (P < .05). LIMITATIONS Observational study in a tertiary center. CONCLUSIONS In Barrett's maximal segments of 5 cm or less, the 2- to 5-o'clock arc, accounts for approximately 50% of macroscopically visible lesions and associated early neoplasia. This finding has important implications for surveillance strategies.
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Affiliation(s)
- Viraj C Kariyawasam
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
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Ishimura N, Amano Y, Uno G, Yuki T, Ishihara S, Kinoshita Y. Endoscopic characteristics of short-segment Barrett's esophagus, focusing on squamous islands and mucosal folds. J Gastroenterol Hepatol 2012; 27 Suppl 3:82-7. [PMID: 22486877 DOI: 10.1111/j.1440-1746.2012.07079.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIM Endoscopic definitions of Barrett's esophagus (BE) vary among countries, mainly because of the difficulty in diagnosing short-segment BE (SSBE) endoscopically. The aim of this study was to investigate whether the endoscopic identification of squamous islands and the specific position of columnar epithelium helps improve the diagnosis of SSBE. METHODS First, we prospectively enrolled 100 consecutive patients with SSBE and evaluated the number of identified squamous islands in the columnar epithelium with different modalities: white light (WL), narrow band imaging (NBI), and iodine chromoendoscopy. Second, in another group of 100 consecutive patients with tongue-like SSBE, the correlation of the location of Barrett's mucosa to the esophageal longitudinal folds (ridge or valley) was evaluated endoscopically. RESULTS It was possible to detect squamous islands in 48, 71, and 75 patients by WL, NBI, and iodine chromoendoscopy, respectively. The detection rate of squamous islands by NBI or iodine chromoendoscopy was significantly superior to that by WL. Tongue-like SSBEs were predominantly found on the ridge of mucosal folds (71%), similar to the location of mucosal breaks (84%). CONCLUSIONS Squamous islands in the columnar epithelium were efficiently observed by NBI or iodine chromoendoscopy. SSBE was found more frequently on the ridges but not in the valleys of esophageal longitudinal mucosal folds. NBI endoscopic observation focusing on columnar epithelium with squamous islands on the ridges of distal esophageal folds may improve endoscopic detection of SSBE.
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Affiliation(s)
- Norihisa Ishimura
- Second Department of Internal Medicine, Shimane University School of Medicine, Izumo, Japan
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Measurement of mucosal conductivity by MII is a potential marker of mucosal integrity restored in infants on acid-suppression therapy. J Pediatr Gastroenterol Nutr 2011; 53:120-3. [PMID: 21694551 DOI: 10.1097/mpg.0b013e318214c3cc] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Esophageal multichannel intraluminal impedance (MII) allows measurement of the conductivity of adjacent contents. During esophageal rest, raw impedance levels may represent mucosal integrity. We assessed the influence of proton pump inhibitors (PPIs) on presumed mucosal integrity by reanalyzing raw MII levels of 21 pH-MII tracings from infants with gastroesophageal reflux (GER) disease before and after esomeprazole treatment. Median (interquartile range) esophageal MII increased during treatment, 938 (652-1304) versus 1885 (1360-2183) Ohm, P < 0.0001. Patients with lower MII levels demonstrated a larger increase on therapy: Spearman r2 = 0.28, P = 0.014. No correlation with standard GER parameters was observed. In conclusion, PPI therapy increases MII levels in infants with symptomatic GER disease.
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Vaezi MF, Slaughter JC, Smith BS, Washington MK, Jerome WG, Garrett CG, Hagaman D, Goutte M. Dilated intercellular space in chronic laryngitis and gastro-oesophageal reflux disease: at baseline and post-lansoprazole therapy. Aliment Pharmacol Ther 2010; 32:916-24. [PMID: 20735783 DOI: 10.1111/j.1365-2036.2010.04420.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Dilation of intercellular spaces is reported to be an early morphological marker in gastro-oesophageal reflux. It remains unknown if this marker is useful in diagnosing reflux-related chronic laryngitis. AIM To determine histopathology and electron microscopic changes in oesophageal and laryngeal epithelium in chronic laryngitis. METHODS In this prospective blinded study, we enrolled 53 participants: 15 controls, 20 patients with GERD and 18 patients with chronic laryngitis. The latter two groups were subsequently treated with lansoprazole 30 mg bid for 12-weeks. Baseline and postacid suppressive therapy biopsies were obtained from distal oesophagus and laryngeal postcricoid areas. Biopsy specimens were evaluated for histopathology and dilated intercellular space changes. RESULTS There was no significant increase in oesophageal or laryngeal epithelium intercellular spaces among GERD or laryngitis patients compared with controls at baseline or postacid suppressive therapy. Only patients with GERD had significantly (P = 0.03) higher proportion of moderate-to-severe oesophageal spongiosis and basal cell hyperplasia, which normalized postacid suppressive therapy. CONCLUSIONS There was no increase in the width of intercellular spaces in the oesophagus or larynx in GERD or chronic laryngitis at baseline or postacid suppressive therapy. Our findings question the uniform presence of dilated intercellular space in patients with GERD.
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Affiliation(s)
- M F Vaezi
- Vanderbilt University Medical Center, Nashville, TN 37232-5280, USA.
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Long-term outcome of microscopic esophagitis in chronic GERD patients treated with esomeprazole or laparoscopic antireflux surgery in the LOTUS trial. Am J Gastroenterol 2010; 105:1015-23. [PMID: 19904246 DOI: 10.1038/ajg.2009.631] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Gastroesophageal reflux disease (GERD)-associated changes in esophageal histology have been reported mainly after short-term medical antireflux therapy, and few individual lesions have been examined. We report detailed histological findings from the LOTUS study, at baseline and at 1 and 3 years after laparoscopic antireflux surgery (LARS) or esomeprazole treatment in patients with chronic GERD. METHODS LOTUS is a long-term, open, parallel-group, multicenter, randomized, controlled trial conducted in 11 European countries that compared LARS (n=248) with esomeprazole 20-40 mg daily (n=266). Biopsies from the distal esophagus 2 cm above the Z-line and at the Z-line were taken at baseline, and 1 and 3 years. The following lesions were assessed: basal cell hyperplasia (BCH), papillary elongation (PE), intercellular space dilatations (ISDs), intraepithelial eosinophils (EOSs), neutrophils, and necrosis/erosion. A severity score (SS, range 0-2) was calculated by taking the average score of all assessable lesions. RESULTS All lesions were more severe on Z-line biopsies than at 2 cm, and almost all improved significantly from baseline to 1 and 3 years. The average SS (from 2 cm to Z-line) changed from 0.95 to 0.57 (1 year) and to 0.49 (3 years) on esomeprazole, and from 0.91 to 0.56 (1 year) and to 0.52 (3 years) after LARS (P<0.001 for both treatments at 1 and 3 years, with no significant difference between treatments). The proportions of patients with severe histological changes decreased from approximately 50% at baseline to 11% at 3 years. CONCLUSIONS Both continuous esomeprazole treatment and laparoscopic fundoplication are associated with significant and similar overall improvement in microscopic esophagitis after 1 year that is maintained at 3 years.
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Martineau H, Thompson H, Taylor D. Pathology of gastritis and gastric ulceration in the horse. Part 2: a scoring system. Equine Vet J 2010; 41:646-51. [PMID: 19927582 DOI: 10.2746/042516409x464799] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
REASONS FOR PERFORMING STUDY High numbers of racehorses in training are reported to have gastric ulceration. Gross lesion scoring systems exist, but there is no fixed protocol with which to record gastric microscopic findings. In man, the histological classification of stomach lesions helps in the identification of recognised and emerging aetiologies of gastric disease and aids accurate comparison of findings between studies. In horses, the development of such a system would therefore be of benefit. OBJECTIVES To develop a pathological scoring system that can be applied to examine samples of the equine stomach at biopsy and post mortem. METHODS AND RESULTS The equine gastritis grading (EGG) system was developed initially using horse stomachs at post mortem. The protocol involved sampling tissue from 5 fixed locations within the squamous and glandular regions. Histological examination recorded both type and degree of inflammatory infiltrate and the presence of erosions, ulceration or any other reactive change in each slide. These results were combined and an overall diagnosis of gastritis type given for each stomach. CONCLUSIONS AND POTENTIAL RELEVANCE This is the first example of a complete pathological scoring system developed specifically for recording gastric lesions in the horse. It provides a thorough and repeatable method with which to examine the equine stomach in microscopic detail. It can be used in diagnostic or research situations and the consistency of the information gathered will enable accurate comparison of data between different studies. It aims to give an indication as to the currently undetermined pathological variations seen in the stomach of healthy and diseased horses, as well as increasing the understanding of the pathogenesis of gastritis and gastric ulceration. Using this information, interpretation of biopsy samples is improved.
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Affiliation(s)
- H Martineau
- Glasgow University Veterinary School, Glasgow, UK
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Inci K, Edebo A, Olbe L, Casselbrant A. Expression of protease-activated-receptor 2 (PAR-2) in human esophageal mucosa. Scand J Gastroenterol 2009; 44:664-71. [PMID: 19263271 DOI: 10.1080/00365520902783683] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The role of duodenal reflux in gastroesophageal reflux disease (GERD) containing bile salts and pancreatic enzymes (with special attention to trypsin) is still under discussion. Proteinase-activated receptors (PARs) are a novel family and PAR-2 is a unique member of this family because it is activated by trypsin. The aim of the present study was to examine the presence and the position of the PAR-2 receptor in human esophageal mucosa in different subgroups of GERD. MATERIAL AND METHODS Distal biopsies taken from healthy controls, patients with erosive reflux disease (ERD), patients with specialized intestinal metaplasia (SIM) and adenocarcinoma were analyzed for the PAR-2 receptor with reverse-transcription polymerase chain reaction (RT-PCR), Western blotting and immunohistochemistry. RESULTS Gene transcripts for the PAR-2 receptor were found in all groups, with increased levels in SIM patients compared to controls. However, this visual pattern was not seen for the protein expression of the PAR-2 receptor showing no apparent quantitative differences between the groups. Immunohistochemistry revealed distinct staining for the PAR-2 receptor in the luminal part of the esophageal epithelium. CONCLUSIONS The localization of the PAR-2 receptor indicates that the receptor can be cleaved and activated by trypsin in duodenogastric esophageal refluxate. The data thus suggest that the trypsin-PAR-2 pathway may be involved in the pathogenesis of GERD.
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Affiliation(s)
- Kamuran Inci
- Department of Gastrosurgical Research and Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Abstract
Gastroesophageal reflux disease (GERD) is a common disease frequently encountered by surgical pathologists. Although the pathogenesis and clinical features of the disease have been studied for years, many unanswered questions remain. Typical clinical symptoms along with the endoscopic findings, pH monitoring, and biopsies, all support the diagnosis. However, these tests may yield conflicting findings, and at present there is no gold standard for the diagnosis of GERD. In patients with normal or nearly normal endoscopic findings (nonerosive reflux disease), the major diagnostic burden lies with the histology. The histologic diagnosis of GERD is based on a combination of findings, including basal cell hyperplasia, papilla elongation, inflammation, and dilatation of intercellular spaces. However, these features exhibit varying sensitivity and specificity, and minimal biopsy criteria for the diagnosis of reflux esophagitis have not been rigorously tested in well-characterized patient populations. However, given the high prevalence of GERD, pathologists face esophageal mucosal biopsies daily and must recognize the diagnostic strengths and limitations of histologic features of reflux esophagitis. Future studies and new techniques may improve the diagnostic strength of histology and establish meaningful minimal criteria for the diagnosis of reflux esophagitis.
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Barrett's esophagus in Japanese patients: its prevalence, form, and elongation. J Gastroenterol 2009; 43:928-34. [PMID: 19107336 DOI: 10.1007/s00535-008-2261-y] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2008] [Accepted: 07/13/2008] [Indexed: 02/04/2023]
Abstract
BACKGROUND Barrett's esophagus is a well-known acquired condition resulting from gastroesophageal reflux disease (GERD). However, it is still unknown whether Barrett's esophagus develops gradually over time in patients with GERD. To address this issue, we investigated the change in the prevalence and length of short-segment Barrett's esophagus (SSBE) over time. METHODS From January 2005 to March 2007, we enrolled 5338 patients who received upper gastrointestinal endoscopy. Prevalence and length of endoscopically identified SSBE were evaluated within groups divided on the basis of 10-year age intervals. The factors possibly influencing SSBE length such as symptoms, antacid use, and endoscopic findings were also evaluated. Additionally, the length change in 236 patients with histologically confirmed Barrett's esophagus was evaluated over a 2-year follow-up. RESULTS Of the 5338 enrolled patients, 1997 had SSBE. The prevalence of endoscopically identified SSBE was significantly higher and its length was significantly longer in elderly patients. Multiple regression analysis showed that age, presence of reflux esophagitis, reflux symptoms, and hiatal hernia were positively correlated with SSBE length. Analysis of the 2-year follow-up study of histologically confirmed SSBE revealed significant extension of Barrett's length in 28.0% of 236 patients. Presence of reflux symptoms and hiatal hernia were identified as positive predictors and proton pump inhibitor administration as a negative predictor of SSBE elongation. CONCLUSIONS Positive predictors for the extension of SSBE were presence of hiatal hernia and reflux symptoms, but not age.
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Abstract
Histology in reflux disease is still regarded as having low sensitivity and specificity. During the last three decades several histological parameters have been developed, including thickness of basal cell layer, length of epithelial papillae, intraepithelial inflammatory cells and dilation of intercellular spaces. Unfortunately classification of these parameters was often not related to the clinical symptoms of the reflux affected individuals, proper control subjects were often missing and often no interobserver variation was given. Another reason for the proposed low value of biopsies is the fact that biopsies were often taken in a non-standardised way. Recent studies point towards an area of predominantly epithelial damage close to the lesser curvature or around the right oesophageal wall. In parallel, some large, careful studies carried out recently showed a good correlation with the clinical picture of reflux disease due to a standardised biopsy protocol and proper controls. But biopsies are not recommended in all routine classical cases of reflux disease since it is believed that little further information in addition to endoscopy can be obtained. However, histology can deliver much more information than the diagnosis of reflux induced lesions (e.g. the exclusion of malignancy or other oesophageal diseases).
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Affiliation(s)
- Michael Vieth
- Institute of Pathology, Klinikum Bayreuth, Preuschwitzer Strasse 101, 95445 Bayreuth, Germany.
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Amano Y, Yamashita H, Koshino K, Ohshima T, Miwa H, Iwakiri R, Fujimoto K, Manabe N, Haruma K, Kinoshita Y. Does magnifying endoscopy improve the diagnosis of erosive esophagitis? J Gastroenterol Hepatol 2008; 23:1063-8. [PMID: 18554240 DOI: 10.1111/j.1440-1746.2008.05453.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND AIMS Low-grade erosive esophagitis (i.e. Los Angeles grade A) is the most predominant type of esophagitis in Japan. It is unclear whether all the mucosal breaks detected by conventional endoscopy are indicative of esophageal mucosal erosion. Hospital-based, cross-sectional, cross-over, observational study was assigned to investigate the value of magnifying endoscopy for diagnosis of erosive esophagitis. METHODS From August to December 2006, 178 consecutive patients with upper gastrointestinal symptoms were enrolled at three university hospitals and one national medical center in western Japan. Before endoscopy, all participants were requested to answer questionnaires concerning their symptoms. Experienced endoscopists performed an endoscopic diagnosis of each patient first with a conventional standard view and then with a magnifying view. Endoscopic diagnostic concordance between conventional and magnifying endoscopic view for erosive esophagitis was calculated. Relationship between a variety of symptoms and erosive esophagitis was also evaluated. RESULTS Erosive esophagitis was identified using conventional and magnifying endoscopy in 14.6% and 17.4% of patients, respectively. Eleven false-negative and six false-positive diagnoses using conventional endoscopy occurred among the 178 enrolled patients. The weighted kappa value of diagnostic concordance for erosive esophagitis between the two endoscopic views was 0.76. The prevalence of erosive esophagitis in patients with reflux-, dysmotility-, and ulcer-like symptoms was 20.7%, 24.1%, and 15.2%, respectively. CONCLUSIONS Magnifying endoscopy did not significantly improve the diagnostic sensitivity of erosive esophagitis over non-magnifying, conventional endoscopy. Erosive esophagitis was frequently identified in patients that did not have reflux symptoms.
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Affiliation(s)
- Yuji Amano
- Division of Gastrointestinal Endoscopy, Shimane University Hospital, Izumo, Japan.
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