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

Esophageal Inlet Patch: Association with Barrett's Esophagus

BACKGROUND

Esophageal inlet patch (IP) with heterotopic gastric mucosa is an incidental finding on esophagogastroduodenoscopy (EGD). Although IP is thought to be embryologic in nature, IP has been associated with Barrett's esophagus (BE).

AIMS

The aim of this study was to compare prevalence, symptoms, demographic factors, and esophageal testing in patients with IP and BE.

METHODS

We retrospectively analyzed endoscopic findings of EGDs, high-resolution esophageal manometry and esophageal pH impedance studies from January 2010 to January 2021 at a single academic medical center. Patients were grouped by presence or absence of IP and BE.

RESULTS

Of 27,498 patients evaluated, 1.3% had endoscopic evidence of IP and 4.9% had BE. Of 362 patients with IP, 17.1% had BE; of 1356 patients with BE, 4.6% had IP. Both IP and BE patients presented primarily with heartburn and/or regurgitation. Patients with BE and/or IP were older and had higher BMI than those without (p < 0.001). Mean lower esophageal sphincter pressure was lower and mean acid exposure time (AET) was higher in patients with IP and/or BE than those without (p < 0.05).

CONCLUSIONS

Our study reports an IP prevalence of 1.3%, with 17.1% patients having concomitant BE; and a BE prevalence of 4.9%, with 4.6% also having IP. Patients with IP alone presented with similar symptoms to patients with concomitant BE. Esophageal function testing showed that patients with either IP or BE had decreased LES pressures and increased esophageal AET. During endoscopy, patients found to have one of these findings should be carefully examined for the other.

Adenocarcinoma arising from widespread heterotopic gastric mucosa in the cervicothoracic esophagus: a case report

BACKGROUND

In Japan, about 6% of esophageal cancers are adenocarcinomas, although most of them arise from Barrett's epithelium. Adenocarcinoma arising from heterotopic gastric mucosa (HGM) is very rare. Due to its rarity, there is no unified view on its treatment strategy and prognosis.

CASE PRESENTATION

A 57-year-old man presented with a protruding lesion in the cervicothoracic esophagus that was detected by an upper gastrointestinal series at a medical checkup. Esophagoscopy revealed a 30 mm Type 1 tumor circumferentially surrounded by widespread HGM. Computed tomography (CT) and fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT showed no metastasis or invasion of the surrounding organs. We diagnosed the lesion as cT2N0M0 cStageIIB [Union for International Cancer Control (UICC) 8th Ed] cancer and performed subtotal esophagectomy with three-field lymph node dissection. The tumor was determined to be a well-differentiated adenocarcinoma arising from HGM, with deep invasion of the submucosa. The patient underwent no adjuvant therapy and has currently survived without any evidence of recurrence for 15 months.

CONCLUSIONS

Although the treatment for adenocarcinoma arising from HGM is basically the same as that for squamous cell carcinoma (SCC) of the esophagus, it is important to determine the treatment strategy based on the characteristics of the adenocarcinoma arising from HGM.

Heterotopic Gastric Mucosa in the Proximal Esophagus: Prospective Study and Systematic Review on Relationships with Endoscopic Findings and Clinical Data

Cervical inlet patches (CIP) are common endoscopic findings with uncertain pathogenesis and clinical significance. We aimed to perform a systematic review and prospective study of clinical data and endoscopic findings related to CIP. It was a prospective single-center study conducted between 10/01/2017 and 9/01/2018. Forty patients with histopathologically confirmed CIP were compared with 222 individuals in the reference group. The systematic review was executed in accordance with the PRISMA guideline. Alcohol consumption tended to be higher among patients with CIP (3.0 ± 4.6 vs. 1.9 ± 5.0 standard drinks/week CIP patients and reference group, respectively; p < 0.001). Dysphagia was more frequent among patients with CIP (25% vs. 1.4%, CIP patients and reference group, respectively; p < 0.001), and sore throat and hoarseness were less frequent in patients with CIP (17.5% vs. 26.6% CIP patients and reference group, respectively; p < 0.01). In the multivariate regression analysis, the only risk factor of CIP occurrence was dysphagia (OR 21.9, 95%CI 4.9-98.6; p < 0.001). Sore throat and hoarseness were a reverse-risk factor of CIP diagnosis (OR 0.3, 95%CI 0.1-0.93; p = 0.04). Clinical data and coexisting endoscopic findings were not related to CIP. In the presented study, dysphagia was related to CIP occurrence, and sore throat and hoarseness tended to be less frequent among patients with CIP.

Cervical esophageal adenocarcinoma of intestinal type in ectopic gastric mucosa

A 45‐year‐old man underwent esophagogastroduodenoscopy because of symptoms of laryngopharyngeal discomfort. We found a protruded reddish lesion adjacent to the ectopic gastric mucosa (EGM) in the cervical esophagus, and a biopsy revealed that it was a tubular adenocarcinoma. We diagnosed the patient with intramucosal cancer and performed endoscopic submucosal dissection. Esophageal endoscopic submucosal dissection was performed under general anesthesia using a conventional procedure. The resected tumor measured 23 × 14 mm and was adjacent to the EGM. Histologically, the tumor cells showed moderately well‐differentiated adenocarcinoma confined to the muscularis mucosa with no lymphovascular infiltration. Immunohistochemically, the tumor cells were positive for intestinal markers, namely MUC2 and CD10, and negative for gastric markers, namely MUC5AC and MUC6. The patient had no post‐endoscopy submucosal dissection stenosis and remained disease‐free without local recurrence. EGM of the cervical esophagus develops from the columnar epithelium during embryonic development. There are few reports on endoscopic submucosal dissection for mucosal cancer. Of these, immunostaining was performed in three cases. All were positive for MUC5AC and MUC6 and negative for MUC2 and CD10. Usually, EGM shows gastric type epithelium, but occasional cases with intestinal metaplasia, which show positivity for MUC2 and CD10, have been reported. Therefore, we consider this to be an extremely rare case of esophageal adenocarcinoma arising from intestinal metaplasia within the EGM.

Argon Plasma Coagulation of Gastric Inlet Patches of the Cervical Esophagus Relieves Vocal and Respiratory Symptoms in Selected Patients

OBJECTIVES

Argon plasma coagulation (APC) of gastric inlet patches of the cervical esophagus (GIP) has been shown to relieve the globus sensation. This study aimed to investigate the long-term effects of APC therapy on a variety of laryngopharyngeal symptoms.

METHODS

Patients with laryngopharyngeal symptoms who had undergone endoscopic GIP eradication via APC therapy were eligible for a retrospective observational cohort study. Symptom relief was assessed by a five-grade scale during a structured interview. Statistical analysis included ANOVA, the chi-squared and t-test.

RESULTS

A total of 45 patients (61.0 (52.0; 69.0) years, 26 (57.8%) female) were included after a follow-up time of 85.0 (55.3; 111.0) months. Symptoms included dysphagia (56.0%), dysphonia (51.0%), hoarseness (76.0%), the necessity of throat clearing (73.0%), globus sensation (56.0%) and heartburn (71.0%). Complete GIP eradication was achieved after one session in 25 (55.6%), repetitive sessions were needed in the remaining cases. Fourteen patients (31.1%) reported a very strong, 11 (24.4%) a strong and 8 patients (17.8%) an intermediate improvement; five patients did not benefit. The most apparent improvement was seen regarding hoarseness (from 2.6 ± 1.7 to 1.2 ± 1.3), the necessity of throat clearing (from 2.6 ± 1.7 to 1.1 ± 1.3), globus sensation (from 2.0 ± 1.9 to 0.9 ± 1.3) and heartburn (from 2.5 ± 1.8 to 1.4 ± 1.6). Adverse events included post-endoscopic pain (n = 6, 13.3%) and purulent pharyngitis (n = 2, 4.4%).

CONCLUSIONS

The APC therapy of GIP is safe and leads to long-term relief of laryngopharyngeal symptoms in carefully selected patients.

Heterotopic Gastric Mucosa in Middle Esophagus Complicated with Esophageal Ulcers

Heterotopic gastric mucosa (HGM) of esophagus, primarily occurring in cervical esophagus, is usually asymptomatic. A healthy woman (mid-40s) with postprandial heartburn was diagnosed with middle esophageal HGM and esophageal ulcers by esophagogastroduodenoscopy. Using 8-channel pH monitoring, a sensor near the HGM area detected postprandial acid phase (pH 3-4), while areas adjacent to the proximal and distal sensors were neutral, suggesting acid secretion from the HGM. A biopsy showed fundic gland tissue expressing H⁺/K⁺-ATPase and pepsinogen-I. Oral vonoprazan improved the clinical symptoms and endoscopic findings. This is the first report using 8-channel pH monitoring to diagnose extremely rare middle esophageal HGM.

Prevalence and Clinical and Endoscopic Characteristics of Cervical Inlet Patch (Heterotopic Gastric Mucosa): A Systematic Review and Meta-Analysis

BACKGROUND

Cervical inlet patch (CIP), also called gastric inlet patch, is a heterotopic columnar mucosal island located in the cervical esophagus, which has been under-recognized by clinicians.

AIM

We conducted a systemic review and meta-analysis to explore the prevalence and clinical and endoscopic characteristics of CIP.

MATERIALS AND METHODS

Studies were searched through the PubMed, EMBASE, and Cochrane Library databases. The prevalence of CIP with 95% confidence interval (CI) was pooled by using a random-effect model. The association of CIP with demographics, clinical presentations, and endoscopic features was evaluated by odds ratios (ORs).

RESULTS

Fifty-three studies including 932,777 patients were eligible. The pooled prevalence of CIP was 3.32% (95% CI=2.86%-3.82%). According to the endoscopic mode, the pooled prevalence of CIP was higher in studies using narrow-band imaging than in those using white light and esophageal capsule endoscopy (9.34% vs. 2.88% and 0.65%). The pooled prevalence of CIP was higher in studies where the endoscopists paid specific attention to the detection of this lesion (5.30% vs. 0.75%). CIP was significantly associated with male (OR=1.24, 95% CI=1.09-1.42, P=0.001), gastroesophageal reflux disease (OR=1.32, 95% CI=1.04-1.68, P=0.03), reflux symptoms (OR=1.44, 95% CI=1.14-1.83, P=0.002), dysphagia (OR=1.88, 95% CI=1.28-2.77, P=0.001), throat discomfort (OR=4.58, 95% CI=1.00-21.02, P=0.05), globus (OR=2.95, 95% CI=1.52-5.73, P=0.001), hoarseness (OR=4.32, 95% CI=1.91-9.78, P=0.0004), cough (OR=3.48, 95% CI=1.13-10.72, P=0.03), Barrett's esophagus (OR=2.01, 95% CI=1.37-2.94, P=0.0003), and esophagitis (OR=1.62, 95% CI=1.27-2.07, P=0.0001).

CONCLUSION

CIP appears to be common by using narrow-band imaging, especially if the endoscopists would like to pay attention to the detection of this lesion. CIP is clearly associated with acid-related symptoms and Barrett's esophagus.

Influence of narrow-band imaging (NBI) and enhanced operator's attention during esophagus inspection on cervical inlet patches detection

PURPOSE

Heterotopic gastric mucosa in the upper esophagus (cervical inlet patches - CIP) may be easily missed during esophagogastroduodenoscopy (EGD) due to low awareness of this usually, but not invariably, benign lesion. Narrow-band imaging (NBI) emphasizes contrast between normal esophageal mucosa and CIP. The purpose of this study was to investigate how NBI use and enhanced attention of operator during inspection of upper esophagus impacts cervical inlet patch detection rate (CIPDR).

MATERIALS AND METHODS

This is a prospective, randomized study in which we enrolled 1000 patients, qualified for diagnostic EGD. The trial was divided into two parts; the first, when 6 operators performed EGD with standard attention (SA), and the second, when the same operators were asked to step up with attention at CIP (enhanced attention - EA). In both parts of the study, patients were randomized to NBI and white light endoscopy (WLE) in 1:1 ratio. The study is registered in ClinicalTrials.gov (No. NCT03015571).

RESULTS

Differences in CIPDR between WLE and NBI in SA and EA were not statistically different (5.6% vs 7.6%; p ​= ​0.3, and 7.6% vs 11.6%; p ​= ​0.1, respectively). In multivariate regression analysis, the only factors improving CIPDR were NBI with EA (NBI_EA, OR 3.31; 95%CI 1.57-6.98; p ​= ​0.003) and sedation (OR 1.97; 95%CI 1.27-3.05; p ​= ​0.002).

CONCLUSIONS

The use of NBI combined with EA significantly improves CIPDR.

Cervical squamous cell carcinoma coexisting with ectopic gastric mucosa treated by endoscopic submucosal dissection: A case report

A 69-year-old Japanese man underwent an endoscopic submucosal dissection (ESD) for early gastric cancer 2 years prior to admission at Fukuchiyama City Hospital. A follow-up esophagogastroduodenoscopy (EGD) revealed a butterfly-shaped brownish area in the cervical esophagus. A successful endoscopic submucosal dissection of the esophageal lesion was performed for total biopsy. Histopathological analysis of the resected specimen revealed moderately differentiated squamous cell carcinoma of the esophagus, cervical esophagus tumor type 0-IIb, a tumor diameter of 14x8 mm, T1b pathological findings (invading into submucosa), infiltrative growth α, lymphatic invasion (-), venous invasion (-), a horizontal tumor free margin and a vertical tumor free margin. The results demonstrated that the squamous cell carcinoma had invaded into the submucosal layer under the ectopic gastric mucosa. After endoscopic treatment, chemoradiation therapy was administered to the patient.

Gastric inlet patches: symptomatic or silent?

PURPOSE OF REVIEW

The purpose of this review is to assess recent literature on the clinical relevance of the gastric inlet patch with particular focus on endoscopic diagnosis and treatment, the relationship of the inlet patch to laryngopharyngeal reflux disease and the association of proximal esophageal adenocarcinoma with inlet patch.

RECENT FINDINGS

Recent studies suggest endoscopic diagnosis of inlet patch increases with endoscopist awareness (up to 10-fold) and when using enhanced imaging techniques such as narrow band imaging (up to three-fold). The literature remains mixed on the association of inlet patch with laryngopharyngeal symptoms or globus sensation. Studies of endoscopic ablation, using argon plasma coagulation or radiofrequency ablation have shown improved laryngopharyngeal reflux symptom scores posttreatment. Proximal esophageal adenocarcinomas are rare but often associated with inlet patch when they occur. Case studies have described endoscopic resection of malignant lesions related to inlet patch, using endoscopic mucosal resection or submucosal dissection.

SUMMARY

Prospective, multicenter studies of symptom association with inlet patch using validated symptom questionnaires and blinded sham-controlled treatments are needed to further clarify the role of such treatments, which to date are limited to a small numbers of centers with a special interest.

Issues and controversies in esophageal inlet patch

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

Prevalence of esophageal inlet patch and clinical characteristics of the patients

INTRODUCTION AND AIMS

An inlet patch (IP) is the presence of gastric columnar epithelium outside of the stomach. No studies have been conducted in Mexico on that pathology. The aim of the present study was to determine the prevalence of esophageal IP and the clinical characteristics of the patients that present it.

MATERIALS AND METHODS

A cross-sectional study was conducted that included consecutive patients referred for endoscopy within the time frame of September 2015 to May 2016. The patients answered a questionnaire, and high-definition endoscopy with digital chromoendoscopy was performed. The prevalence of IP was identified. The chi-square test was used to compare the clinical characteristics between patients that presented with esophageal IP and those without it.

RESULTS

A total of 239 patients were included in the study. Their mean age was 53 years, and 130 (54.4%) were women. IP was found in 26 patients (10.9%), 15 of whom were men (57.7%). The main reason for referral to endoscopy was gastroesophageal reflux disease, present in 69.2% of the patients with IP and in 55.9% without IP (p=.19). The most common symptoms were heartburn and regurgitation. The former was present in 69.2% of the patients with IP and in 59.1% without IP (p=.32), and the latter was present in 65.4% of the patients with IP and 69.1% without IP (p=.7). Extraesophageal manifestation distribution was: cough in 46.2% of the patients with IP and 38% without IP (p=.45) and dysphonia in 54% with IP and 47% without IP (p=.53). Twenty-three percent of the patients with IP had Barrett's esophagus, as did 23% without IP (p=.99).

CONCLUSIONS

The prevalence of IP was high. The primary referral diagnosis was gastroesophageal reflux disease. No differences were found in relation to symptoms or the presence of Barrett's esophagus between the patients with and without IP.

[Heterotopic tissue in the gastrointestinal tract]

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

Cervical inlet patch: new insights into diagnosis and endoscopic therapy

The cervical inlet patch is an island of heterotopic gastric mucosa, most commonly found in the proximal oesophagus. Its importance as a cause of throat symptoms has been recognised, particularly chronic globus sensation. This has led to a change in the Rome IV criteria for globus management, with emphasis on ruling out the condition. Proton pump inhibitors are often ineffective in resolving symptoms. Endoscopic studies on the use of ablative techniques, most recently radiofrequency ablation (RFA), have shown promise in reversing the CIP to mormal squamous mucosa, with subsequent symtpomatic resolution. The aim of this review is to update on the investigation and management of the CIP.

A 14-Year Study of 398 Esophageal Adenocarcinomas Diagnosed Among 156,256 EGDs Performed at Two Large Hospitals: An Inlet Patch Is Proposed as a Significant Risk Factor for Proximal Esophageal Adenocarcinoma

BACKGROUND

An association between inlet patches and proximal esophageal adenocarcinomas is currently suspected because of numerous case reports of simultaneous occurrence of both diseases.

AIMS

To analyze whether inlet patches are significantly associated with proximal esophageal adenocarcinomas in a large population.

METHODS

Computerized search of pathology and EGD reports revealed 398 cases of esophageal adenocarcinomas among 156,236 EGDs (performed on 106,510 patients) diagnosed by histopathology performed at Royal Oak/Troy, William Beaumont Hospitals, 2003-2016. Adenocarcinomas localized as distal, middle, or proximal; and characterized as associated versus unassociated with inlet patches. Medical records were reviewed. Endoscopic photographs, radiologic images, and pathologic slides were re-reviewed. Two researchers independently performed systematic computerized literature searches; cases of simultaneous diseases identified by consensus.

RESULTS

Adenocarcinoma locations included: distal-381, middle-14, and proximal esophagus-3. Five patients had inlet patches with esophageal adenocarcinomas located at: distal-2, middle-0, and proximal esophagus-3 (relative frequency of inlet patches with cancers of distal/middle esophagus = 2/395 [.5%] vs. proximal esophagus = 3/3 [100%], p < .000001, 95% OR CI > 50.1, Fisher's exact test). Cases of proximal esophageal adenocarcinomas within inlet patches included: (1) Seventy-eight-year-old man presented with dysphagia. Neck CT showed proximal esophageal mass. EGD revealed semi-circumferential, multinodular, 3.0 × 1.5 cm mass within inlet patch. Histopathology of biopsies revealed moderately-to-poorly differentiated adenocarcinoma. Patient received chemoradiotherapy and expired 2 years later. (2) Seventy-nine-year-old man presented with anorexia and weight loss. EGD demonstrated proximal esophageal mass within inlet patch. Histopathology of biopsies revealed poorly differentiated, signet ring cell adenocarcinoma. Chest CT revealed 3.4 × 2.1-cm-proximal esophageal mass. Patient expired 4 months later. (3) Sixty-year-old man presented with dysphagia. EGD revealed 4-cm-long, semi-circumferential, proximal esophageal mass within inlet patch. Histopathology of biopsies revealed poorly differentiated adenocarcinoma. Patient underwent emergency esophagectomy for esophageal perforation 2 weeks after initiating chemoradiotherapy, and died shortly thereafter. Literature review revealed 39 cases of simultaneous disease.

STUDY LIMITATIONS

Potential underreporting by endoscopists of inlet patches at EGD.

CONCLUSIONS

Study supplements 39 previously reported cases of simultaneous disease, by adding three new cases, and by novel report of statistically significant association between these two entities, which has important implications in the pathophysiology of proximal esophageal adenocarcinoma.

The prevalence of gastric heterotopia of the proximal esophagus is underestimated, but preneoplasia is rare - correlation with Barrett's esophagus

BACKGROUND

The previously reported prevalence of gastric heterotopia in the cervical esophagus, also termed inlet patch (IP), varies substantially, ranging from 0.18 to 14%. Regarding cases with adenocarcinoma within IP, some experts recommend to routinely obtain biopsies from IP for histopathology. Another concern is the reported relation to Barrett's esophagus. The objectives of the study were to prospectively determine the prevalence of IP and of preneoplasia within IP, and to investigate the association between IP and Barrett's esophagus.

METHODS

372 consecutive patients undergoing esophagogastroduodenoscopy were carefully searched for the presence of IP. Biopsies for histopathology were targeted to the IP, columnar metaplasia of the lower esophagus, gastric corpus and antrum. Different definitions of Barrett's esophagus were tested for an association with IP.

RESULTS

At least one IP was endoscopically identified in 53 patients (14.5%). Histopathology, performed in 46 patients, confirmed columnar epithelium in 87% of cases, which essentially presented corpus and/or cardia-type mucosa. Intestinal metaplasia was detected in two cases, but no neoplasia. A previously reported association of IP with Barrett's esophagus was weak, statistically significant only when short segments of cardia-type mucosa of the lower esophagus were included in the definition of Barrett's esophagus.

CONCLUSIONS

The prevalence of IP seems to be underestimated, but preneoplasia within IP is rare, which does not support the recommendation to regularly obtain biopsies for histopathology. Biopsies should be targeted to any irregularities within the heterotopic mucosa. The correlation of IP with Barrett's esophagus hints to a partly common pathogenesis.

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

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

Esophageal Inlet Patch: An Under-Recognized Cause of Symptoms in Children

OBJECTIVES

To determine the incidence of inlet patch (IP) and to assess the clinical and pathological features, role of the diagnostic workup in treatment decision making, efficacy of medical and endoscopic therapy, and natural history in a pediatric population.

STUDY DESIGN

Consecutive patients aged <18 years (n = 1000) undergoing esophagogastroduodenoscopy were enrolled prospectively. Biopsy specimens were obtained from IPs and the proximal and distal esophagus, stomach, and duodenum. Multichannel intraluminal impedance and pH monitoring (MII-pH) was performed in all symptomatic patients. Symptomatic patients were treated with proton pump inhibitors for 8 weeks, and IP ablation by argon plasma coagulation (APC) was performed in unresponsive patients.

RESULTS

The endoscopic incidence of IP was 6.3%, with a cumulative missing rate of 5.8%. Thirty-five of the 63 patients (56%) were asymptomatic, 11 (17%) had symptoms clearly related to the underlying digestive disorder, and 17 (27%) had chronic IP-related symptoms. MII-pH was positive in 10 of the 28 symptomatic patients. All 17 patients with IP-related symptoms were unresponsive to proton pump inhibitors and were treated with APC, and all had achieved complete remission by the 3-year follow-up. Patients with underlying disorders were successfully treated with medical therapy, and asymptomatic patients remained symptom-free, with no endoscopic or histological changes seen at the 3-year follow-up.

CONCLUSION

IP is an under-recognized cause of symptoms in children with unexplained esophageal and respiratory symptoms. MII-pH and bioptic sampling are needed to exclude entities mimicking IP symptoms and to direct therapy. APC is safe and effective for treating IP-related symptoms.

Intentional examination of esophagus by narrow-band imaging endoscopy increases detection rate of cervical inlet patch

Foci of heterotopic gastric mucosa have been identified at different sites in the human body and the most common location is the proximal esophagus which is referred to as cervical inlet patch (CIP). The true prevalence of CIP varies and it is usually incidental findings during endoscopy. Because CIP is always asymptomatic, it was believed to be of little clinical relevance. However, emerging studies have described the acid-secreting characteristics of heterotopic gastric mucosa and associations of CIP with gastroesophageal reflux disease (GERD). In addition, complications such as stricture, fistula, infection, mucosal hyperplasia, and malignant transformation have been reported. In this study, we investigated the prevalence of CIP, its associations with clinical manifestations, and the effect of intentional screening upper esophagus by magnifying endoscopy-narrow-band imaging (ME-NBI) system. Consecutive healthy adults who underwent panendoscopy were separated into two groups. Patients in group I (n = 471) were examined by an endoscopist who intended to find CIPs by ME-NBI. Patients in group II (n = 428) were examined by two endoscopists who were unaware of the study and performed white-light imaging endoscopy. Participants provided questionnaires on GERD-related symptoms. Higher CIP prevalence (11.7% vs. 1.9%, P < 0.0001) and longer duration of esophageal examination (mean ± standard deviation, 17.50 ± 12.40 vs. 15.24 ± 10.78 seconds, P = 0.004) were noted in group I than in group II. Analyzing group I patients revealed the higher prevalences of reflux symptoms (32.7% vs. 18.3%, P = 0.013) and erosive esophagitis (43.6% vs. 25.5%, P = 0.005) in patients with CIP than in those without. CIP was not associated with globus or dysphagia symptoms. More small CIPs (< 5 mm) were detected by ME-NBI than by white-light imaging (85.3% vs. 41.4%, P = 0.001). In conclusion, CIP prevalence was not low under intentional ME-NBI examination of the upper esophagus. The clinical relevance of CIP and its association with GERD require further investigation.

Long segments of columnar-lined lower esophagus are not always metaplastic

The presence of columnar epithelium in the esophagus is associated with two conditions: Barrett's esophagus and heterotopic gastric mucosa. The former results from the metaplastic replacement of the normal distal squamous esophageal lining, is associated with gastroesophageal reflux and is a pre-neoplastic condition. The second is thought as a congenital condition, resulting from the incomplete squamous epithelialization of the esophagus during embryologic development. It is found mainly in the cervical esophagus. Histologically, Barrett's esophagus is composed of an admixture of cardiac mucosa, oxintocardiac mucosa and intestinal metaplasia. Most of heterotopic gastric mucosa consists of oxynticmucosa where the mucosal glands are straight and composed of parietal and chief cells.There are few reports of heterotopic gastric mucosa in the lower esophagus, generally presenting as small islands. In the present report, a series of four cases of large lower esophageal heterotopic gastric mucosa is described. All patients were initially misdiagnosed with Barrett's esophagus and referred for surveillance. The correct diagnosis was based in endoscopic and histological features. In all, a circular tiny strip of squamous mucosa was observed at endoscopy between the lower end of the columnarlined esophagus and the esophagogastric junction, defined as the proximal end of the gastric folds. Biopsy samples taken from the columnar-lined segments of the four patients showed pure oxyntic mucosa.When columnar-lined esophagus is observed in the distal esophagus not in continuity with gastric mucosa, the diagnosis of heterotopic gastric mucosa must be thought and confirmed histologically by the presence of pure oxyntic mucosa.

Prevalence, histologic and clinical characteristics of heterotopic gastric mucosa in Chinese patients

AIM: To determine the prevalence, demographic, clinical and histopathologic features of heterotopic gastric mucosa (HGM) in Chinese patients.

METHODS: Patients referred to three endoscopy units were enrolled in this study. The macroscopic characteristics of HGM were documented. Biopsies were obtained and observed using hematoxylin and eosin staining. Helicobacter pylori colonization was examined by Whartin-Starry staining.

RESULTS: HGM was observed in 420 Chinese patients, yielding a prevalence of 0.4%. The majority of patients had a single patch (300/420; 71.4%), while the remainder had two (84/420; 20%) or multiple patches (36/420; 8.6%). The size of the patches and the distance from the patch to the frontal incisor teeth varied significantly. The large majority of HGM patches were flat (393/420; 93.6%), whereas the remaining patches were slightly elevated. The primary histological characteristic was fundic-type (216/420; 51.4%) within the HGM patch, and antral- (43/420; 10.2%) and transitional-type (65/420; 15.5%) mucosa were also observed. The prevalence of intestinal metaplasia was 3.1% (13/420) and the prevalence of dysplasia was 1.4% (6/420), indicating the necessity for endoscopic follow-up in patients with HGM. Esophageal and extraesophageal complaints were also observed in patients with HGM. Dysphagia and epigastric discomfort (odds ratios: 6.836 and 115.826, respectively; Ps < 0.05) were independent risk factors for HGM.

CONCLUSION: Clinical complaints should be considered to improve the detection rate of HMG. The prevalence of intestinal metaplasia and dysplasia also indicates a need for endoscopic follow-up.

Heterotopic gastric mucosa of upper oesophagus: evaluation of 12 cases during gastroscopic examination

INTRODUCTION

Oesophageal heterotopic gastric mucosa mostly presents in the upper part of the oesophagus. It is commonly under-diagnosed because of its localisation.

AIM

To expose the association between heterotopic gastric mucosa and endoscopic features of the upper gastrointestinal tract.

MATERIAL AND METHODS

A total of 1860 upper endoscopic examinations performed between January 2012 and July 2013 were analysed retrospectively. Endoscopic features and histological examinations of 12 heterotopic gastric mucosa (HGM) of the upper oesophagus were documented and evaluated retrospectively.

RESULTS

There were 7 (58%) male and 5 (42%) female patients aged between 22 and 80 years with a mean age of 43.2 years. Heterotopic gastric mucosa was present in 12 (0.6%) of all patients. We were able to perform biopsy for histopathological observation on 8 (66%) of the 12 patients in which HGM was seen during endoscopy. Five (42%) patients with heterotopic gastric mucosa had oesophagitis. Los Angeles Grade A oesophagitis was found in all patients, and histologically proven Barrett's oesophagus was detected in only one patient.

CONCLUSIONS

When a patient has ongoing dyspeptic complaints and reflux symptoms despite the treatment, one should be careful about possible HGM during upper gastrointestinal endoscopy. The point to be taken into consideration for patients who have metaplasia or dysplasia within HGM may need to be considered for surveillance.

Argon plasma coagulation of gastric inlet patches for the treatment of globus sensation: it is an effective therapy in the long term

AIM

To determine the long-term effect of argon plasma coagulation (APC) of gastric inlet patches in the cervical esophagus for patients suffering from globus sensation.

METHODS

We intended to follow up all patients between 2004 and 2011 (n = 49) who received argon plasma ablation of gastric inlet patches for globus sensation at our clinic. Symptoms were assessed by a visual analogue scale (VAS) in 31 of 49 patients. Follow-up endoscopy of the upper gastrointestinal tract was performed to confirm residual or relapsed cervical inlet patches.

RESULTS

After a median period of 27 months, APC was assessed as a successful therapy in 23 of 31 patients (74%). VAS scores decreased significantly from 7.6 to 4.0 in the long term. Twenty-two of 31 patients were willing to undergo follow-up endoscopy. Endoscopy revealed recurrent/residual gastric inlet patches after APC in 11 of 22 cases. These patients suffered from a significant relapse of symptoms in the postinterventional period (p < 0.001).

CONCLUSION

This retrospective study indicates that APC of gastric inlet patches for the treatment of globus sensation might be a sufficient therapy option. Recurrences or residual heterotopic gastric mucosa are possible and seem to be associated with a relapse of symptoms. Therefore, endoscopic follow-up and retreatment might be necessary if globus sensation is not sufficiently eliminated.

Heterotopic gastric mucosa of the gastrointestinal tract: prevalence, histological features, and clinical characteristics

BACKGROUND

Heterotopic gastric mucosa (HGM) may be located at sites throughout the gastrointestinal (GI) tract. Clinical characteristics of HGM, role of Helicobacter pylori infection, natural history, and relationship to neoplastic transformation have not sufficiently been explored.

AIM

To retrospectively study the prevalence, histological features, and clinical characteristics of HGM among Chinese patients who underwent upper GI endoscopy.

METHODS

Endoscopic, histological, and clinical records of patients, who underwent upper GI endoscopy (n = 6802) and colonoscopy (n = 3504), respectively, between May 2011 and May 2012, were collected and retrospectively analyzed. A total of 6716 sex- and age-matched patients without HGM were enrolled as controls.

RESULTS

HGM was diagnosed in 86 cases (51 esophageal, 0.75%; 35 duodenal, 0.51%). Male:female ratio was 1.4:1 (30/21) for esophageal HGM, 1.7:1 (22/13) for duodenal HGM, and 1.1:1 (3557/3159) for controls. Two histopathological types of HGM were identified: foveolar epithelium alone and foveoloar epithelium together with gastric glands. Helicobacter pylori were present in 19.6% of cases with esophageal HGM and 20.0% of cases with duodenal HGM. Esophageal HGM was significantly associated with dysphagia and globus; duodenal HGM was not significantly associated with GI symptoms. Intestinal metaplasia was present in two and three patients in both groups, respectively, with no dysplasia or carcinoma.

CONCLUSION

HGM was present in fewer patients undergoing upper GI endoscopy, and it was more often present in men. A careful endoscopic examination is required to diagnose HGM, and it should be supported with a biopsy when indicated.

Review on novel concepts of columnar lined esophagus

BACKGROUND

Columnar lined esophagus (CLE) is a marker for gastroesophageal reflux and associates with an increased cancer risk among those with Barrett's esophagus. Recent studies fostered the development of integrated CLE concepts.

METHODS

Using PubMed, we conducted a review of studies on novel histopathological concepts of nondysplastic CLE.

RESULTS

Two histopathological concepts-the squamo-oxyntic gap (SOG) and the dilated distal esophagus (DDE), currently model our novel understanding of CLE. As a consequence of reflux, SOG interposes between the squamous lined esophagus and the oxyntic mucosa of the proximal stomach. Thus the SOG describes the histopathology of CLE within the tubular esophagus and the DDE, which is known to develop at the cost of a shortened lower esophageal sphincter and foster increased acid gastric reflux. Histopathological studies of the lower end of the esophagus indicate, that the DDE is reflux damaged, dilated, gastric type folds forming esophagus and cannot be differentiated from proximal stomach by endoscopy. While the endoscopically visible squamocolumnar junction (SCJ) defines the proximal limit of the SOG, the assessment of the distal limit requires the histopathology of measured multilevel biopsies. Within the SOG, CLE types distribute along a distinct zonation with intestinal metaplasia (IM; Barrett's esophagus) and/or cardiac mucosa (CM) at the SCJ and oxyntocardiac mucosa (OCM) within the distal portion of the SOG. The zonation follows the pH-gradient across the distal esophagus. Diagnosis of SOG and DDE includes endoscopy, histopathology of measured multi-level biopsies from the distal esophagus, function, and radiologic tests. CM and OCM do not require treatment and are surveilled in 5 year intervals, unless they associate with life quality impairing symptoms, which demand medical or surgical therapy. In the presence of an increased cancer risk profile, it is justified to consider radiofrequency ablation (RFA) of IM within clinical studies in order to prevent the progression to dysplasia and cancer. Dysplasia justifies RFA ± endoscopic resection.

CONCLUSIONS

SOG and DDE represent novel concepts fusing the morphological and functional aspects of CLE. Future studies should examine the impact of SOG and DDE for monitoring and management of gastroesophageal reflux disease (GERD).

Clinical significance of heterotopic gastric mucosal patch of the proximal esophagus

Heterotopic gastric mucosa of the proximal esophagus (HGMPE), also referred to as “inlet patch” or “cervical inlet patch”, is a salmon colored patch that is usually located just distal to the upper esophageal sphincter. HGMPE is uncommon with endoscopic studies reporting a prevalence ranging from less than one percent to 18%. Most HGMPE are asymptomatic and are detected incidentally during endoscopy for evaluations of other gastrointestinal complaints. Most consider HGMPE as clinically irrelevant entity. The clinical significance of HGMPE is mainly acid related or neoplastic transformation. The reported prevalence of laryngopharyngeal reflux symptoms varies from less than 20% to as high as 73.1%. However, most of these symptoms are mild. Clinically significant acid related complications such as bleeding, ulcerations, structure and fistulization have been reported. Although rare, dysplastic changes and malignancies in association with HGMPE have also been reported. Associations with Barrett’s esophagus have also been reported but the findings so far have been conflicting. There are still many areas that are unknown or not well understood and these include the natural history of HGMPE, risk factors for complications, role of Helicobacter pylori infection and factors associated with malignant transformations. Follow-up may need to be considered for patients with complications of HGMPE and surveillance if biopsies show intestinal metaplasia or dysplastic changes. Despite the overall low incidence of clinically relevant manifestations reported in the literature, HGMPE is a clinically significant entity but further researches are required to better understand its clinical significance.

Primary esophageal adenocarcinoma arising from heterotopic gastric mucosa: report of a case

Adenocarcinoma arising from heterotopic gastric mucosa (HGM) is exceedingly rare. This report presents the case of a 57-year-old male who presented with the chief complaint of dysphagia. Endoscopy and computed tomography revealed a locally advanced tumor of the cervical esophagus and swollen mediastinal lymph nodes. He underwent chemoradiotherapy followed by esophagectomy with three-field lymph node dissection. The resected tumor was a circumferentially scarred lesion located 1.5 cm from the proximal margin. The tumor was identified to be a well-differentiated adenocarcinoma arising from HGM with invasion to the muscularis propria. Postoperative chemoradiotherapy was performed because positive surgical margins were observed in the resected tissue. The patient has remained alive for more than 4 years after surgery, without any evidence of recurrence.

Gastric heterotopia in the proximal oesophagus ("inlet patch"): Association with adenocarcinomas arising in Barrett mucosa

BACKGROUND

The prevalence of inlet patches and their association with other conditions of the gastrointestinal tract have been studied prospectively in tertiary care facilities; little is known about practice patterns in private outpatient clinics and endoscopy centres.

AIMS

To assess prevalence, demographic determinants, and associated clinicopathologic features of inlet patches in patients who had oesophagogastroduodenoscopy in outpatient settings throughout the United States.

METHODS

Retrospective analysis of the clinicopathologic records of 487,229 unique patients who had oesophagogastroduodenoscopy with biopsies between January 2008 and December 2010.

RESULTS

There were 870 patients with inlet patches with a prevalence of 0.18%. Significant associations included male gender (OR 1.68), dysphagia (OR 1.34), upper respiratory complaints (OR 2.81), globus (OR 5.39) Barrett oesophagus (OR 1.55), and adenocarcinomas arising in Barrett mucosa (OR 5.64).

CONCLUSIONS

The prevalence of inlet patches in a tertiary care setting (0.18%) was considerably lower than reported in prospective studies (3.7% on average). Inlet patches were significantly associated with male gender, dysphagia, upper respiratory complaints, globus, Barrett mucosa, and adenocarcinomas arising in Barrett oesophagus. Further studies will be needed to determine if patients with inlet patches and Barrett mucosa benefit from increased surveillance.