Barrett's esophagus: the long and the short of it

Association of Barrett's esophagus with Helicobacter pylori infection: a meta-analysis

Background and Aims:

Barrett’s esophagus (BE) is the only recognized precursor for esophageal adenocarcinoma. Helicobacter pylori (H. pylori) infection is a major contributing factor towards upper gastrointestinal diseases, but its relationship with BE remains controversial. Some previous studies suggested that H. pylori infection negatively correlated with BE, while others did not. This may be attributed to the difference in the selection of control groups among studies. The present meta-analysis aims to clarify their association by combining all available data from well-designed studies.

Methods:

The PubMed, EMBASE, and Cochrane Library databases were searched. Odds ratios (ORs) with 95% confidence intervals (CIs) were pooled by a random-effects model. Heterogeneity was evaluated using the Cochran’s Q test and I² statistics. Meta-regression, subgroup, and leave-one-out sensitivity analyses were employed to explore the sources of heterogeneity.

Results:

Twenty-four studies with 1,354,369 participants were included. Meta-analysis found that patients with BE had a significantly lower prevalence of H. pylori infection than those without (OR = 0.53, 95% CI = 0.45–0.64; p < 0.001). The heterogeneity was statistically significant (I² = 79%; p < 0.001). Meta-regression, subgroup, and leave-one-out sensitivity analyses did not find any source of heterogeneity. Meta-analysis of 7 studies demonstrated that CagA-positive H. pylori infection inversely correlated with BE (OR = 0.25, 95% CI = 0.15–0.44; p = 0.000), but not CagA-negative H. pylori infection (OR = 1.22, 95% CI = 0.90–1.67; p = 0.206). Meta-analysis of 4 studies also demonstrated that H. pylori infection inversely correlated with LSBE (OR = 0.39, 95% CI = 0.18–0.86; p = 0.019), but not SSBE (OR = 0.73, 95% CI = 0.30–1.77; p = 0.484).

Conclusion:

H. pylori infection negatively correlates with BE. More experimental studies should be necessary to elucidate the potential mechanisms in future.

Factors Associated With Outcomes in Endoscopic Submucosal Dissection of Gastric Cardia Tumors: A Retrospective Observational Study

Tumors of the gastric cardia are among the most technically difficult lesions to remove by endoscopic submucosal dissection (ESD). This study aimed to evaluate the therapeutic outcomes of ESD in gastric cardia tumors according to clinicopathologic characteristics, and to assess the predictive factors for incomplete resection.We conducted a retrospective observational study of 82 patients with adenomas and early cancers of the gastric cardia who underwent ESD between January 2006 and December 2013 at the Pusan National University Hospital. Therapeutic outcomes of ESD and procedure-related complications were analyzed.En bloc resection, complete resection, and curative resection rates were 87%, 79%, and 66%, respectively. Deep submucosal invasion was the most common cause of noncurative resection in the cases in which complete resection was achieved. On multivariate analyses, hemispheric distribution (anterior hemisphere; odds ratio [OR] 4.808) and depth of tumor invasion (submucosal cancer; OR 22.056) were independent factors associated with incomplete resection. The rates of procedure-related bleeding, perforation, and stenosis were 6%, 1%, and 0%, respectively; none of the complications required surgical intervention.In conclusion, ESD is a safe, effective, and feasible treatment for gastric cardia tumors. However, the complete resection rate decreases for tumors that are located in the anterior hemisphere or have deep submucosal invasion.

Barrett's oesophagus diagnostic criteria: endoscopy and histology

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

The Barrett's Gland in Phenotype Space

Barrett's esophagus is characterized by the erosive replacement of esophageal squamous epithelium by a range of metaplastic glandular phenotypes. These glandular phenotypes likely change over time, and their distribution varies along the Barrett's segment. Although much recent work has addressed Barrett's esophagus from the genomic viewpoint-its genotype space-the fact that the phenotype of Barrett's esophagus is nonstatic points to conversion between phenotypes and suggests that Barrett's esophagus also exists in phenotype space. Here we explore this latter concept, investigating the scope of glandular phenotypes in Barrett's esophagus and how they exist in physical and temporal space as well as their evolution and their life history. We conclude that individual Barrett's glands are clonal units; because of this important fact, we propose that it is the Barrett's gland that is the unit of selection in phenotypic and indeed neoplastic progression. Transition between metaplastic phenotypes may be governed by neutral drift akin to niche turnover in normal and dysplastic niches. In consequence, the phenotype of Barrett's glands assumes considerable importance, and we make a strong plea for the integration of the Barrett's gland in both genotype and phenotype space in future work.

Barrett oesophagus: lessons on its origins from the lesion itself

Barrett oesophagus develops when the lower oesophageal squamous epithelium is replaced with columnar epithelium, which shows both intestinal and gastric differentiation. No consensus has been reached on the origin of Barrett oesophagus. Theories include a direct origin from the oesophageal-stratified squamous epithelium, or by proximal migration of the gastric cardiac epithelium with subsequent intestinalization. Variations of this theory suggest the origin is a distinctive cell at the squamocolumnar junction, the oesophageal gland ducts, or circulating bone-marrow-derived cells. Much of the supporting evidence comes from experimental models and not from studies of Barrett mucosa. In this Perspectives article, we look at the Barrett lesion itself: at its phenotype, its complexity, its clonal architecture and its stem cell organization. We conclude that Barrett glands are unique structures, but share many similarities with gastric glands undergoing the process of intestinal metaplasia. We conclude that current evidence most strongly supports an origin from stem cells in the cardia.

Central obesity in asymptomatic volunteers is associated with increased intrasphincteric acid reflux and lengthening of the cardiac mucosa

BACKGROUND & AIMS

In the West, a substantial proportion of subjects with adenocarcinoma of the gastric cardia and gastroesophageal junction have no history of reflux. We studied the gastroesophageal junction in asymptomatic volunteers with normal and large waist circumferences (WCs) to determine if central obesity is associated with abnormalities that might predispose individuals to adenocarcinoma.

METHODS

We performed a study of 24 healthy, Helicobacter pylori-negative volunteers with a small WC and 27 with a large WC. Abdominal fat was quantified by magnetic resonance imaging. Jumbo biopsy specimens were taken across the squamocolumnar junction (SCJ). High-resolution pH-metry (12 sensors) and manometry (36 sensors) were performed in upright and supine subjects before and after a meal; the SCJ was visualized fluoroscopically.

RESULTS

The cardiac mucosa was significantly longer in the large WC group (2.5 vs 1.75 mm; P = .008); its length correlated with intra-abdominal (R = 0.35; P = .045) and total abdominal (R = 0.37; P = .034) fat. The SCJ was closer to the upper border of the lower esophageal sphincter (LES) in subjects with a large WC (2.77 vs 3.54 cm; P = .02). There was no evidence of excessive reflux 5 cm above the LES in either group. Gastric acidity extended more proximally within the LES in the large WC group, compared with the upper border (2.65 vs 4.1 cm; P = .027) and peak LES pressure (0.1 cm proximal vs 2.1 cm distal; P = .007). The large WC group had shortening of the LES, attributable to loss of the distal component (total LES length, 3 vs 4.5 cm; P = .043).

CONCLUSIONS

Central obesity is associated with intrasphincteric extension of gastric acid and cardiac mucosal lengthening. The latter might arise through metaplasia of the most distal esophageal squamous epithelium and this process might predispose individuals to adenocarcinoma.

Differences in the Characteristics of Barrett's Esophagus and Barrett's Adenocarcinoma between the United States and Japan

In Europe and the United States, the incidence of esophageal adenocarcinoma has increased 6-fold in the last 25 years and currently accounts for more than 50% of all esophageal cancers. Barrett's esophagus is the source of Barrett's adenocarcinoma and is characterized by the replacement of squamous epithelium with columnar epithelium in the lower esophagus due to chronic gastroesophageal reflux disease (GERD). Even though the prevalence of GERD has recently been increasing in Japan as well as in Europe and the United States, the clinical situation of Barrett's esophagus and Barrett's adenocarcinoma differs from that in Western countries. In this paper, we focus on specific differences in the background factors and pathophysiology of these lesions.

Clinical predictors for response to proton pump inhibitor treatment in patients with globus

Background/Aims

Globus is a persistent or intermittent non-painful sensation of a lump or foreign body in the throat. Given the benign nature of the condition and the association of gastroesophageal reflux disease, empirical therapy with proton pump inhibitor seems reasonable for patients with typical globus. The aim of this study was to investigate the clinical predictors for symptom response to short-term proton pump inhibitor treatment in patients with globus symptom.

Methods

Fifty-four patients with globus symptom were enrolled prospectively. All patients were treated with pantoprazole 40 mg daily for 4 weeks. Treatment response was defined as a > 50% reduction in symptom scores between symptom assessments. Univariate and multivariate logistic regression analysis between responders and non-responders was performed to identify variables predicting response to pantoprazole treatment.

Results

Of the 54 consecutive patients considered, 13 were excluded on the basis of exclusion criteria and/or refusal to participate in the study. Finally, 41 patients were included in this study. After 4-week pantoprazole treatment, 22 patients (53.7%) were classified as responders. On multivariate analysis, the presence of reflux symptom was associated with a higher response rate to 4-week pantoprazole treatment (OR, 68.56; P = 0.043), and long symptom duration (≥ 3 months) were associated with a lower response rate to pantoprazole treatment (OR, 0.03; P = 0.034).

Conclusions

Presence of reflux symptom and short symptom duration were independent predictors of responsiveness to 4-week pantoprazole treatment in patients with globus.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Endoscopic grading of gastroesophageal flap valve helps predict proton pump inhibitor response in patients with gastroesophageal reflux disease

OBJECTIVE

Limited information is available on predictors of the response to proton pump inhibitor (PPI) treatment in patients with gastroesophageal reflux disease (GERD). Endoscopic grading of gastroesophageal flap valve (GEFV) is simple and reproducible, and can provide useful information on patients with suspected reflux undergoing an endoscopy. The aim of this study was to prospectively identify predictors, including endoscopic findings such as GEFV, for PPI treatment outcomes in patients with GERD.

MATERIAL AND METHODS

One hundred and fifty consecutive patients with GERD were enrolled. All patients were treated with pantoprazole 40 mg daily for 8 weeks. Treatment response was defined as greater than 50% reduction in symptom scores between the two symptom assessments (i.e., over 4 or 8 weeks). Univariate and multivariate logistic regression analyses between responders and non-responders were performed to identify variables predicting response to pantoprazole treatment.

RESULTS

Of the 150 consecutive patients considered for this study, 31 were excluded based on exclusion criteria and/or refusal to participate, leaving 119 eligible patients. After 4-week pantoprazole treatment, 70 of 119 (58.8%) patients were classified as responders. Patients with obesity and Helicobacter pylori infection demonstrated a higher response rate to 4-week pantoprazole treatment (odds ratio (OR) 5.28, p = 0.008; OR 3.76, p = 0.023, respectively). Patients with abnormal GEFV showed a lower response rate to 4-week treatment (OR 0.17, p = 0.016). After 8-week treatment, 86 of 119 (72.3%) patients were classified as responders. Abnormal GEFV and aspirin intake were associated with a lower response rate to 8-week treatment (OR 0.17, p = 0.021; OR 0.11, p = 0.020, respectively).

CONCLUSIONS

Abnormal GEFV was a significant independent factor predicting poor response to both 4-week and 8-week pantoprazole treatment. Endoscopic grading of GEFV provides useful information for predicting the response to PPI treatment in patients with GERD.

Does short-segment columnar-lined esophagus elongate during a mean follow-up period of 5.7 years?

BACKGROUND

The length of Barrett's esophagus is considered to be important because it is associated with the risk of neoplasia. In Japan, there is a high prevalence of short-segment columnar-lined esophagus (SS-CLE). The natural history of SS-CLE is not fully understood, so the aim of the present study was to investigate the chronological changes of SS-CLE.

METHODS

The subjects were 500 consecutive patients with SS-CLE (327 men and 173 women; mean age: 64.0 years) diagnosed between January 2001 and July 2002 at our hospital based on the definition of SS-CLE proposed by the Japanese Society for Esophageal Diseases. Follow-up endoscopy was carried out annually for a mean period of 5.7 ± 1.2 years. The cumulative probability of SS-CLE showing elongation was estimated by the Kaplan-Meier method, and factors related to endoscopic findings making an independent contribution to elongation were determined with Cox's proportional hazard model.

RESULTS

Elongation of SS-CLE occurred in 29 patients (5.8%) during the follow-up period and the cumulative 5-year probability of elongation was 16.6%. There was no progression of SS-CLE to Barrett's adenocarcinoma. The absence of atrophic gastritis (adjusted odds ratio (aOR): 23.4; 95%CI [6.5, 83.8]), the presence of reflux esophagitis (aOR: 4.53; 95%CI [1.2, 16.4]), and the flame-shaped type of SS-CLE (aOR: 22.4; 95%CI [7.8, 64.0]) were found to be independent contributors to the elongation of SS-CLE.

CONCLUSIONS

The present study demonstrated that SS-CLE remains stable in length over time, especially in patients without atrophic gastritis, as well as in those with reflux esophagitis and/or flame-shaped SS-CLE at initial examination.

Acid reflux and oesophageal cancer

Barrett's metaplasia is one of the commonest premalignant lesions in the western world following colorectal adenomas. One in 50 of the adult population develops Barrett's as a consequence of chronic gastro-oesophageal reflux. The mucosal inflammation seen within patients with gastro-oesophageal reflux seems likely to drive the growth of the metaplastic mucosa and also help direct further oncological change, yet the molecular events that characterize the pathway from inflammation to metaplasia to dysplasia and adenocarcinoma are poorly understood. There is hope that understanding the role of oesophageal inflammation will provide important insight into the development of Barrett's metaplasia and oesophageal cancer. This chapter will discuss the inflammation seen within context of Barrett's oesophagus and also clinical trials which hope to address this common premalignant disease. There are several ongoing clinical trials which are aiming to provide data using anti-inflammatory therapies to tackle this important premalignant condition. There is new data presented which suggests that data from the aspirin esomeprazole chemoprevention trial (AspECT) may hold the clue to disease treatment and that the cytokine TNF-α seems to be a key signalling molecule in the metaplasia-dysplasia-carcinoma sequence. Specifically it appears that both epigenetic and inherited genetics cooperate to modulate the prognosis.

Where are you and how do we find you? The dilemma of identifying Barrett's epithelium before adenocarcinoma of the esophagus

The incidence of esophageal adenocarcinoma in white males has been increasing steadily over the past decade. However, attempts to identify the precursor lesion, intestinal metaplasia of the esophagus, or early in-situ cancers have been dismal, with no increase in the diagnosis of early cancers over 9 years of follow-up, as noted in the study by Cooper et al. Important predictors of survival,such as a previous diagnosis of gastroesophageal reflux disease, endoscopy, and the diagnosis of intestinal metaplasia, continue to represent a minority of patients who present with esophageal adenocarcinoma. A discussion on the possible pathophysiology, and reasons for the poor diagnostic yields in spite of performing more endoscopies, are presented. It may be that most patients are relatively asymptomatic, or have very distal, endoscopically imperceptible intestinal metaplasia. Over time, factors that encourage localized, distal esophageal reflux may be the insidious culprit that leads to intestinal metaplasia.

Changing trends in the proportion of adenocarcinoma of the esophagogastric junction in a large tertiary referral center in Japan

INTRODUCTION

A dramatic increase in incidence of adenocarcinoma of the esophagogastric junction (EGJ) over the past two decades has been reported in the West. However, epidemiological data from Asian countries have not shown a similar trend. The aim of this study was to determine the incidence of adenocarcinoma of the EGJ in a cohort of consecutive patients operated on for gastric adenocarcinoma at a major cancer referral center in Japan.

METHOD

We reviewed pathological reports of all patients who underwent surgery for advanced gastric adenocarcinoma between 1962 and 2005 at the National Cancer Centre Hospital in Tokyo. Adenocarcinoma of the EGJ was defined from images recorded for each patient, in accordance with the classification of Siewert and Stein. The proportion of adenocarcinoma at the EGJ among operated gastric adenocarcinoma patients was compiled at five-year intervals and serial comparison made.

RESULTS

A total of 6953 patients with advanced gastric adenocarcinoma were operated on; adenocarcinoma of EGJ was found in 520 patients. The overall proportion of adenocarcinoma of the EGJ increased from 2.3% (1962-1965) to 10.0% (2001-2005). The proportion of Siewert Type II rose from 28.5% (1962-1965) to 57.3% (2001-2005), while that of Type I remained at around 1%.

CONCLUSION

An increasing trend of adenocarcinoma of EGJ is observed in this study of patients operated on for gastric adenocarcinoma from 1962 to 2005 in a large tertiary referral center in Japan.

Is ineffective esophageal motility associated with gastropharyngeal reflux disease?

AIM: To evaluate the association between ineffective esophageal motility (IEM) and gastropharyngeal reflux disease (GPRD) in patients who underwent ambulatory 24-h dual-probe pH monitoring for the evaluation of supraesophageal symptoms.

METHODS: A total of 632 patients who underwent endoscopy, esophageal manometry and ambulatory 24-h dual-pH monitoring due to supraesophageal symptoms (e.g. globus, hoarseness, or cough) were enrolled. Of them, we selected the patients who had normal esophageal motility and IEM. The endoscopy and ambulatory pH monitoring findings were compared between the two groups.

RESULTS: A total of 264 patients with normal esophageal motility and 195 patients with the diagnosis of IEM were included in this study. There was no difference in the frequency of reflux esophagitis and hiatal hernia between the two groups. All the variables showing gastroesophageal reflux and gastropharyngeal reflux were not different between the two groups. The frequency of GERD and GPRD, as defined by ambulatory pH monitoring, was not different between the two groups.

CONCLUSION: There was no association between IEM and GPRD as well as between IEM and GERD. IEM alone cannot be considered as a definitive marker for reflux disease.

Tongue-like Barrett’s esophagus is associated with gastroesophageal reflux disease

AIM: To test this hypothesis of barrett esophagus (BE) classified into two types and to further determine if there was any correlation between the shape of endoscopically suspected esophageal metaplasia (ESEM), prevalence of reflux esophagitis (RE) and heartburn.

METHODS: A total of 6504 Japanese who underwent endoscopy for their annual stomach check-up were enrolled in this study. BE was detected without histological confirmation that is ESEM. We originally classified cases of ESEM into 3 types based on its shape: Tongue-like (T type), Dome-like (D type) and Wave-like (W type) ESEM. The respective subjects were prospectively asked to complete questionnaires concerning the symptoms of heartburn, dysphagia, and abdominal pain for a one-month period.

RESULTS: ESEM was observed in 10.3% of 6504 subjects (ESEM < 1 cm, 9.4%; 1 cm ≤ ESEM < 3 cm, 1.7%; ESEM ≥ 3 cm, 0.5%). The frequency of ESEM was significantly higher in males compared with female subjects. Statistical analysis showed that the prevalence of heartburn and RE were significantly higher in the T type ESEM than in the W type ESEM (P < 0.05).

CONCLUSION: The T type ESEM was strongly asso-ciated with reflux symptoms and RE whereas the W type ESEM was not associated with GERD.

Low proportion of Barrett's esophagus in Asian Americans

OBJECTIVES

To determine the proportion of Barrett's esophagus (BE) in Asians versus non-Asians and the predictors of BE in patients with upper gastrointestinal (GI) symptoms.

METHODS

We performed a cross-sectional study to determine the proportion of BE from all consecutive patients who underwent esophagogastroduodenoscopy (EGD) for various indications at an outpatient, community-based gastroenterology practice in northern California from February 2000 to September 2006. BE was defined as endoscopically recognized presence of salmon-pink mucosa in the distal esophagus and intestinal metaplasia on biopsy. We also performed a nested case-control study to determine potential predictors of BE.

RESULTS

In total, 5,293 patients were reviewed. BE was more common in non-Asians (31/1464, 2.1%) than Asians (29/3829, 0.76%) (P < 0.001). In multivariate analysis controlling for increasing age, male gender, ethnicity, smoking, and alcohol, the strongest predictor of the presence of BE was non-Asian ethnicity (odds ratio [OR] 3.55, 95% confidence interval [CI] 1.85-6.85), followed by male gender (OR 2.68, 95% CI 1.32-5.45).

CONCLUSION

BE is uncommon in Asian Americans; non-Asian ethnicity and male gender are significant independent predictors of BE.

Barrett's esophagus: pathogenesis, treatment, and prevention

Esophageal adenocarcinoma is the most common type of esophageal cancer seen in the United States and Western Europe. Barrett's esophagus (BE) is a well-known risk factor for esophageal adenocarcinoma and is believed to be found in 6% to 12% of patients undergoing endoscopy for gastroesophageal reflux disease and in more than 1% of all patients undergoing endoscopy. This article focuses on the pathogenesis, treatment, and prevention of BE.

Clinical characteristics of asymptomatic esophagitis

BACKGROUND

Asymptomatic esophagitis is not rare in gastroesophageal reflux disease. However, little attention has been given to this disease so far. We evaluated the clinical characteristics of patients with asymptomatic esophagitis and determined the factors associated with this disease.

METHODS

A cross-sectional survey was performed of 87 patients with esophagitis, aged 23 to 90 years, diagnosed by endoscopy. We assessed 12 clinical variables at the time of the endoscopy: symptoms, age, sex, severity of esophagitis (Los Angeles classification), grade of gastric mucosal atrophy, presence or absence of Barrett's epithelium and sliding hernia, alcohol, smoking, body-mass index (BMI), comorbid diseases such as hypertension, diabetes and asthma, and medications such as calcium blocker and theophylline.

RESULTS

Most patients had grade A or B esophagitis; 64 patients were symptomatic, and the remaining 23 were asymptomatic. In a univariate analysis, the assessed variables sex, BMI, drinking, and smoking (habit and amount of consumption) were associated with asymptomatic esophagitis (P < 0.05). Then, multivariate logistic analysis performed using these four variables demonstrated that sex, BMI, and smoking (habit and number of cigarettes smoked daily) were significantly and in dependently associated with this disease (P < 0.05).

CONCLUSIONS

Smoking, male sex, and lower BMI are independent factors associated with asymptomatic esophagitis. Since no information is available on the natural history of this disease, we should pay attention to patients with these characteristics.

Reflux esophagitis or Helicobacter infection? - diagnostic value of the inflammatory pattern in metaplastic mucosa at the squamocolumnar junction

OBJECTIVES

Metaplastic glandular mucosa with goblet cells at the squamocolumnar junction is induced either by reflux or by Helicobacter infection. We investigated whether the accompanying inflammation may give information about the etiology of these metaplastic changes and whether there are further criteria which are helpful in differentiating Helicobacter-induced vs. reflux-caused metaplasia.

METHODS

One hundred and nine patients with intestinal metaplasia diagnosed in biopsies obtained immediately below the Z-line were evaluated. Further biopsies were taken from the gastric body and antrum. Patients were diagnosed as having a normal Z-line, or as showing short tongues or segments of Barrett's esophagus endoscopically. Inflammation was graded according to the updated Sydney-system. Metaplasia was typed using Gomori's-aldehyde-fuchsin-Alcianblue staining.

RESULTS

Compared to patients with Barrett's esophagus, the active (p=0.0002) and chronic inflammation (p=0.0004) at the squamocolumnar junction was higher in patients with a normal Z-line and frequently accompanied by lymphoid aggregates (p<0.0001) and regular cardia- (p=0.0044) and/or corpus-type glands (p=0.0004). Pseudogoblet cells were more frequent in Barrett's esophagus (p=0.0159).

CONCLUSIONS

The endoscopic aspect of the Z-line, the inflammatory pattern, and the type of glands in biopsies from the squamocolumnar junction, as well as the presence of pseudogoblet cells are helpful tools in distinguishing Barrett's mucosa from Helicobacter-associated intestinal metaplasia.

Endoscopic grading of gastroesophageal flap valve and atrophic gastritis is helpful to predict gastroesophageal reflux

BACKGROUND AND AIM

The endoscopic grading of the gastroesophageal flap valve (GEFV) has been suggested to be a good predictor of reflux status. Atrophic gastritis is inversely associated with reflux esophagitis. The aim of the present study was to investigate the association between GEFV, atrophic gastritis and gastroesophageal reflux.

METHODS

A total of 608 patients (252 men and 356 women; mean age 51.1 years) who underwent endoscopy, esophageal manometry and ambulatory 24-h pH monitoring were included. GEFV was graded I through IV using Hill's classification: the GEFV was largely classified into two groups: the normal GEFV group (grades I and II) and the abnormal GEFV group (grades III and IV). Atrophic gastritis was classified into two groups by endoscopic atrophic border: closed-type (C-type) and open-type (O-type). Findings of endoscopy, esophageal manometry and ambulatory pH monitoring were compared among the groups.

RESULTS

The incidence of reflux esophagitis and gastroesophageal reflux disease was associated with an abnormal GEFV grade and was inversely associated with open-type atrophic gastritis. The patients with a coexisting abnormal GEFV and closed-type atrophic gastritis showed a significantly higher incidence of reflux esophagitis and gastroesophageal reflux disease than the patients with a coexisting normal GEFV and open-type atrophic gastritis (OR, 20.6 [95% CI, 6.2-68.4], 11.4 [95% CI, 6.3-20.7], respectively).

CONCLUSIONS

Endoscopic grading of GEFV and atrophic gastritis is simple and provides useful information on the status of gastroesophageal reflux.

Is obesity associated with gastropharyngeal reflux disease?

AIM

To examine the association between obesity and gastropharyngeal reflux disease (GPRD) as well as gastroesophageal reflux disease (GERD).

METHODS

We conducted a cross-sectional study of consecutive patients undergoing ambulatory 24-h dual-probe pH monitoring from July 2003 to December 2006. The association between body mass index (BMI) and parameters about gastroesophageal or gastropharyngeal reflux was examined in univariate and multivariate analyses.

RESULTS

A total of 769 patients (307 men and 462 women; mean age 50.7 years) were finally enrolled. Most variables showing gastroesophageal reflux was higher in the obese patients than the patients with normal BMI. There was no difference in all the variables showing gastropharyngeal reflux according to the BMI. After adjustment for age, sex, alcohol intake and smoking, obese patients demonstrated an about 2-fold increase in risk of GERD compared with patients with normal BMI (OR, 1.9; 95 CI, 1.3-2.9), but overweight patients did not demonstrate increased risk of GERD (OR, 1.2; 95 CI, 0.8-1.7). Both obese patients and overweight patients did not demonstrated increased risk of GPRD compared with patients with normal BMI (OR, 1.1; 95 CI, 0.8-1.7; and OR, 0.9; 95 CI, 0.6-1.3, respectively).

CONCLUSION

Obesity is not associated with GPRD reflux while it is associated with GERD.

Cancer risk in Barrett's oesophagus

(Table is included in full-text article.)Barrett's oesophagus results from the replacement of the normal squamous lining of the oesophagus by a columnar epithelium. It is the sole known premalignant condition for oesophageal adenocarcinoma. The annual cancer incidence of 1% in Barrett's oesophagus, calculated from published series, has been recently considered an overestimation owing to publication bias, and a 0.5% risk was proposed. The prerequisite of the presence of intestinal metaplasia for the diagnosis of Barrett's oesophagus, although widely accepted, is questioned by some authors. How adenocarcinoma incidence is influenced by requiring or not intestinal metaplasia for Barrett's oesophagus diagnosis is unknown. Most of the published studies included only (or preferentially) patients with long segments. Data on adenocarcinoma incidence in short segments (<3 cm) are very scarce, but it is believed to be lower than in long segments. The magnitude of cancer risk influences cost effectiveness of surveillance of Barrett's oesophagus. Frequently, therapeutic intervention is performed when high-grade dysplasia is diagnosed, preventing progression to adenocarcinoma. This could lead to an underestimation of cancer risk in Barrett's surveillance studies.

Which landmark results in a more consistent diagnosis of Barrett's esophagus, the gastric folds or the palisade vessels?

BACKGROUND

The endoscopic landmark used to diagnose Barrett's esophagus differs between Japanese and Western endoscopists.

OBJECTIVE

To compare the degree of diagnostic variation in results achieved by Japanese endoscopists when using the palisade vessels as a landmark of the distal esophagus and when using the gastric folds; interobserver diagnostic concordance was evaluated.

DESIGN

Eighty-four endoscopists classified 30 patients with Barrett's esophagus by viewing projected endoscopic photographs. The endoscopists were asked to identify the distal end of the esophagus, first by using the Japanese criteria and later by using the gastric folds after an explanation of the Prague C&M Criteria. Endoscopists were divided into groups according to years in practice as an endoscopist, presence or absence of board certification from the Japan Gastroenterological Endoscopy Society, and whether they had taken any special endoscopic training courses on GERD. The kappa coefficient of reliability was calculated for each group.

RESULTS

The initial overall kappa value for all the endoscopists for the identification of the distal end of the esophagus was only 0.14, an unacceptably low value of concordance over and above chance agreement. The length of experience with diagnostic endoscopy, board license, or special training had no impact on the level of concordance. After an explanation of the C&M Criteria, however, there was a statistically significant improvement in the diagnostic concordance.

CONCLUSIONS

The upper end of the gastric folds, as used in C&M Criteria, may be a more suitable landmark than the palisade vessels for identifying the distal end of the esophagus by endoscopy.

Gastroesophageal flap valve is associated with gastroesophageal and gastropharyngeal reflux

BACKGROUND

The endoscopic grade of the gastroesophageal flap valve (GEFV) is suggested to be a good predictor of reflux status. The aim of this study was to investigate the association of the GEFV and gastroesophageal and gastropharyngeal reflux.

METHODS

A total of 364 patients (151 men and 233 women; mean age, 52.2 years) who underwent endoscopy, esophageal manometry, and ambulatory 24-h dual-probe pH monitoring were included. GEFV was graded I through IV using Hill's classification; then, GEFV was classified into two groups: a normal GEFV group (grades I and II) and an abnormal GEFV group (grades III and IV). Findings of endoscopy, esophageal manometry, and ambulatory pH monitoring were compared between the groups.

RESULTS

Increased GEFV grade was significantly associated with an increased prevalence of both reflux esophagitis and Barrett's epithelium (P < 0.001). Lower esophageal sphincter pressure was significantly lower in the abnormal GEFV group than in the normal GEFV group (P < 0.001). All variables showing gastroesophageal reflux in the distal probe were significantly higher in the abnormal GEFV group than in the normal GEFV group (P < 0.001). In addition, all variables, except the supine time of pH < 4, showing gastropharyngeal reflux in the proximal probe were significantly higher in the abnormal GEFV group than in the normal GEFV group (P < 0.001). The frequency of gastroesophageal reflux disease and of gastropharyngeal reflux disease was significantly higher in the abnormal GEFV group than in the normal GEFV group (P < 0.001).

CONCLUSION

Endoscopic grading of the GEFV is easy and provides useful information about the status of gastroesophageal and gastropharyngeal reflux.

EpCAM and gpA33 are markers of Barrett's metaplasia

AIMS

To characterise a specific and sensitive marker of Barrett's metaplasia (BM).

METHODS

Cases of normal oesophageal squamous mucosa (11 fresh endoscopic biopsies and 10 formalin fixed, paraffin embedded tissue blocks), BM (11 biopsies and 11 tissue blocks), and normal gastric body mucosa (five biopsies and five tissue blocks) were analysed using reverse transcriptase PCR, Western blotting, and immunohistochemistry for EpCAM, and reverse transcriptase PCR for gpA33.

RESULTS

Strong EpCAM mRNA expression was detected in all the BM cases, in contrast to weak expression in all the normal gastric mucosal samples and no expression in any of the normal oesophageal mucosal samples tested. Strong gpA33 mRNA expression was detected in all the BM cases, in contrast to weak expression in a quarter of the normal gastric mucosal samples and no expression in any of the normal oesophageal mucosal samples tested. Western blotting showed EpCAM protein expression in all the BM cases and in none of the normal gastric or oesophageal mucosal samples tested. Immunohistochemistry showed strong EpCAM protein expression in BM and complete absence of expression in normal oesophageal squamous epithelium. Scattered EpCAM expressing cells were found in the gland bases of normal gastric body mucosa.

CONCLUSIONS

EpCAM protein and gpA33 mRNA expressions are specific and sensitive markers of BM.

[Barrett's oesophagus: endoscopic diagnosis and follow-up]

Barrett's oesophagus (BO), or replacement of the squamous mucosa by a specialized intestinal metaplasia due to gastro-oesophageal reflux disease (GORD), predisposes to adenocarcinoma. It is estimated that 6 to 12% of patients undergoing GI endoscopy have short BO (< 3 cm), and 1% have a long BO. Macroscopic diagnosis of BO is sometimes difficult and, in case of doubt, endoscopy should be redone after a period of efficient anti-secretory treatment. Diagnosis of BO is histological and should be confirmed by biopsies. The incidence of adenocarcinoma is globally estimated at 0.5% patient by year of follow-up, and exists for both short and long BO. Due to this low incidence, screening for BO is only justified in patients at high risk for adenocarcinoma (male gender, age > 50 ans, old GORD in a young patient). Low-grade dysplasia (LGD) then high-grade dysplasia (HGD) precedes adenocarcinoma. Histological diagnosis of LGD is difficult: the main cause of confusion is inflammation so diagnosis of LGD must be confirmed after a 3-month high-dose anti-secretory treatment. Diagnosis of HGD is easier but multiple biopsies are needed to determine the focal or multifocal disposition of HGD. The benefit of follow-up of BO is debated. Aged patients should be followed only if dysplasia is present. When dysplasia is absent, an endoscopic control with biopsies is desirable within 3 to 5 years. In case of dysplasia, the latter must be confirmed by another examination of biopsies, particularly in case of suspicion of HGD and after antisecretory treatment. In case of LGD, endoscopy with biopsies should be redone 6 months later to screen for HGD, then every year if LGD is confirmed. In case of HGD, the 5-year risk of cancer is 60% so surgical or endoscopic treatment is usually proposed. If HGD follow-up is decided, it should be performed on a 3- to 6-month basis.

A proposal for a new validated histological definition of the gastroesophageal junction

Present definitions of the gastroesophageal junction (GEJ) are the point of flaring of the tubular esophagus and the proximal limit of the gastric rugal folds. Neither of these has been validated as the true GEJ. This study aims to validate the location of the true GEJ using the criterion of esophageal submucosal glands. Ten esophagogastrectomy specimens, in which there was a well-defined point of flaring of the tubular esophagus that coincided with the proximal limit of gastric rugal folds, were examined by complete histological mapping to evaluate the distribution of esophageal submucosal glands and surface epithelial types. Oxyntocardiac and cardiac mucosa with or without intestinal metaplasia were present under rugal folds distal to the end of tubular esophagus in all patients to a length of 0.31 to 2.05 cm. Submucosal glands were present in the tubular esophagus and in the proximal pouch distal to the tubular esophagus in a distribution that closely coincided with squamous epithelium, oxyntocardiac, cardiac, and intestinal epithelia. Submucosal glands were never found under oxyntic mucosa. We conclude that a variable part of the saccular region distal to the tubular esophagus contains esophageal submucosal glands, therefore representing reflux-damaged distal esophagus. This results in an error, where up to 2.05 cm of distal reflux-damaged dilated esophagus can be mistaken as proximal stomach when presently accepted definitions for the GEJ are used. The true GEJ is the proximal limit of gastric oxyntic mucosa defined by histology.

Increased Barrett's esophagus for the decade between 1991 and 2000 at a single university medical center

Barrett's esophagus is being diagnosed increasingly in the United States. The aim of this study was to determine whether the increased diagnosis of Barrett's esophagus is due to endoscopic reporting and/or a truly increasing rate. This retrospective study reviewed 18,183 endoscopy reports at Temple University Hospital from January 1991 through December 2000. Annual rates of new cases of endoscopically suspected Barrett's esophagus were determined. Biopsy results were reviewed for the diagnosis of Barrett's esophagus (i.e., specialized intestinal metaplasia). Rates of Barrett's esophagus increased from 3.22 to 8.28 per 100 endoscopies (257%; P < 0.01) on endoscopy and from 0.67 to 2.76 per 100 endoscopies (412%; P < 0.01) on histology from 1991 to 2000. Twenty-four and seven-tenths percent (252/1020) of patients suspected at endoscopy to have Barrett's esophagus were confirmed by histology. This study demonstrates an increasing rate of new cases of suspected Barrett's esophagus on endoscopy and confirmed Barrett's esophagus on histology over the last decade. The endoscopic impression of Barrett's esophagus was about four times higher than the confirmed diagnosis of Barrett's esophagus (intestinal metaplasia) on histology.

Cytokeratin 7 and 20 expression in intestinal metaplasia of the distal oesophagus: relationship to gastro-oesophageal reflux disease

AIMS

Intestinal metaplasia and gastro-oesophageal reflux disease typify classical Barrett's oesophagus. Cytokeratin (CK) 7 and 20 phenotypes differentiate intestinal metaplasia in long segment Barrett's oesophagus from gastric intestinal metaplasia. This study examines the relationship between CK7/20 phenotypes and reflux disease in intestinal metaplasia of the distal oesophagus.

METHODS AND RESULTS

Eighty patients with oesophageal pH studies included 30 with long segment Barrett's, 16 with short segment Barrett's and 34 with intestinal meatplasia of the gastro-oesophageal junction. Representative biopsy specimens were immunostained for CK7 and CK20. All 30 long segment patients demonstrated a Barrett's CK7/20 phenotype. All nine short segment patients with gastro-oesophageal reflux had a Barrett's CK7/20 phenotype, while four of seven short segment patients without reflux had a gastric CK7/20 phenotype (P = 0.019). Of 14 patients with intestinal metaplasia of the gastro-oesophageal junction and reflux, 10 (71%) had a Barrett's CK7/20 phenotype, compared with 11 (55%) of the 20 non-reflux patients.

CONCLUSIONS

CK7/20 immunoreactivity for patients with intestinal metaplasia of the distal oesophagus without long segment Barrett's oesophagus suggests a heterogeneous group, with an association between Barrett's CK7/20 pattern and gastro-oesophageal reflux disease in both short segment Barrett's and intestinal metaplasia of the gastro-oesophageal junction.

CDX1 is an important molecular mediator of Barrett's metaplasia

The molecular pathogenesis of Barrett's metaplasia (BM) of the esophagus is poorly understood. The change to an intestinal phenotype occurs on a background of esophagitis due to refluxing acid and bile. CDX1, an important regulator of normal intestinal development, was studied as a potential key molecule in the pathogenesis of BM. CDX1 mRNA and protein were universally expressed in all samples of BM tested but not in normal esophageal squamous or gastric body epithelia. This tissue-specific expression was attributable to the methylation status of the CDX1 promoter. Conjugated bile salts and the inflammatory cytokines TNF-alpha and IL-1beta were all found to increase CDX1 mRNA expression in vitro. These effects were primarily mediated by NF-kappaB signaling but only occurred when the CDX1 promoter was unmethylated or partially methylated. The data suggest that CDX1 is a key molecule linking etiological agents of BM to the development of an intestinal phenotype. Although the initial trigger for CDX1 promoter demethylation is not yet identified, it seems likely that demethylation of its promoter may be the key to the induction and maintenance of CDX1 expression and so of the BM phenotype.

Prediction of malignant potential in reflux disease: are cytokine polymorphisms important?

OBJECTIVES

Esophageal reflux is common in the Western world and can lead to a number of diseases, such as esophagitis, Barrett's esophagus, and adenocarcinoma. Barrett's predisposes to adenocarcinoma and endoscopic surveillance may lead to earlier detection of adenocarcinoma. However, clinical methods only identify one patient in 15 with Barrett's esophagus. The aim of this study was to find factors that may help identify patients with Barrett's earlier.

METHODS

Blood samples and detailed histories were taken from 456 patients with gastroesophageal reflux who were recruited into three study groups: esophagitis, Barrett's esophagus without dysplasia, and Barrett's with dysplasia or adenocarcinoma. PCR was used to determine the frequency of five functional cytokine polymorphisms: interleukin-1 receptor antagonist position +2018 (IL-1 Ra +2018), interleukin-1 beta position -511 (IL-1 beta-511), tumor necrosis factor-alpha position -238 (TNF-alpha-238), interleukin-10 position +1082 (IL-10 +1082), and interleukin-4 receptor position -1902 (IL-4R -1902).

RESULTS

IL-1 Ra +2018 genotype 2/2 was associated with Barrett's more commonly than esophagitis (OR-3.7, p= 0.0345). The IL-10 +1082 genotype 2/2 was more strongly associated with Barrett's and adenocarcinoma than esophagitis (OR-1.76, p= 0.056 and OR 1.96, p= 0.025, respectively). There were no differences for the IL-1 beta-511, IL-4R -1902, and TNF-alpha-238 polymorphisms.

CONCLUSIONS

Cytokine polymorphisms are more commonly found in patients with Barrett's or adenocarcinoma than those with esophagitis. Together with demographic data, this may help identify those patients with Barrett's who would benefit from surveillance.

Inflammation and cytokeratin 7/20 staining of cardiac mucosa in young patients with and without Helicobacter pylori infection

BACKGROUND

Both Helicobacter pylori and gastro-oesophageal reflux disease (GORD) may cause inflammation in cardiac mucosa. Intestinal metaplasia (IM) is found more often in GORD associated inflammation than in inflammation caused by H pylori, especially in young individuals.

AIM

To examine morphological differences in chronic inflammation in these two conditions by immunohistochemistry.

PATIENTS/METHODS

Tissue blocks from cardiac mucosa of patients <45 years were available as follows: 10 patients with chronic inflammation of cardiac mucosa (carditis) and H pylori gastritis (group 1); 10 patients with (possibly GORD related) carditis, but normal antrum and corpus (group 2); and 10 patients with non-inflamed cardiac mucosa and normal antrum and corpus (group 3). Haematoxylin and eosin staining and immunohistochemical staining for various inflammatory cells were performed for patients in groups 1 and 2 as follows: CD20 (B cells), CD3 (T cells), CD4 (T helper cells), CD8 (T suppressor cells), CD163 (macrophages), CD138 (plasma cells), and CD117 (mast cells). For all patients, cytokeratin 7/20 (CK7/20) staining was performed.

RESULTS

No clear differences were seen in the morphology of chronic inflammation between groups 1 and 2. In both, plasma cells were most abundant. CK7/20 staining showed no differences between these groups.

CONCLUSION

Helicobacter pylori negative (possibly GORD associated) and H pylori related carditis cannot be distinguished on a morphological basis. The stronger tendency towards IM in the first entity cannot be explained by differences in the type of inflammation. Barrett-type CK7/20 staining seems typical for cardiac mucosa, irrespective of the type of inflammation or presence of IM.

Carcinoma of the cardia: classification as esophageal or gastric cancer?

INTRODUCTION

The cardia is the anatomical borderland between the esophagus and stomach. Carcinomas of the cardia are regarded to share features of both, esophageal and gastric cancers. Controversy exists concerning their appropriate classification and whether these tumors comprise--in respect to tumor biology, pathophysiology as well as clinical features--an entirely separate entity.

CLASSIFICATION

In order to distinguish cardia carcinomas from other adenocarcinomas arising within the vicinity of the esophagogastric junction, a classification system has been introduced from a surgical viewpoint, and is now well established and increasingly used worldwide. According to the topography of the main tumor mass, cardia carcinomas (AEG II) are distinguished from adenocarcinomas of the distal esophagus (AEG I) and subcardiac gastric cancers (AEG III). The tumor-node-metastasis (TNM) staging system by the International Union Against Cancer (UICC) does not provide a separate classification for tumors of the esophagogastric junction. The use of the classification for esophageal or for gastric cancers is recommended, irrespective of the elementary differences in the classification of lymphatic spread implemented herein.

DISCUSSION

New aspects concerning this controversial debate are discussed based on current insights into the pathogenesis and the cellular origin of these entities. The controversies concerning the classification of cardia carcinomas and the failure of the current esophageal and gastric cancer staging systems to reflect the peculiarities of this entity accurately, present a strong argument in favor of a new classification system.

Barrett esophagus: update for radiologists

Barrett esophagus is a well-recognized entity in which there is progressive columnar metaplasia of the lower esophagus due to longstanding gastroesophageal reflux and reflux esophagitis [1]. This condition is important because it is associated with an increased risk of developing esophageal adenocarcinoma by a well-established sequence from dysplasia to carcinoma [2]. During the past decade, however, an explosion of new data has dramatically affected our understanding of Barrett esophagus. Not only have revised histopathologic criteria been developed for this condition, but it is currently believed that patients with Barrett esophagus should be classified as having "short-segment" or "long-segment" disease based on the extent of columnar metaplasia in the distal esophagus. This distinction has important implications for the risk of developing esophageal adenocarcinoma and subsequent need for endoscopic surveillance. The purpose of this article is to present these new concepts about Barrett esophagus and provide radiologists with a more current framework for diagnosing this condition.

A critical review of the diagnosis and management of Barrett's esophagus: the AGA Chicago Workshop

BACKGROUND & AIMS

The diagnosis and management of Barrett's esophagus (BE) are controversial. We conducted a critical review of the literature in BE to provide guidance on clinically relevant issues.

METHODS

A multidisciplinary group of 18 participants evaluated the strength and the grade of evidence for 42 statements pertaining to the diagnosis, screening, surveillance, and treatment of BE. Each member anonymously voted to accept or reject statements based on the strength of evidence and his own expert opinion.

RESULTS

There was strong consensus on most statements for acceptance or rejection. Members rejected statements that screening for BE has been shown to improve mortality from adenocarcinoma or to be cost-effective. Contrary to published clinical guidelines, they did not feel that screening should be recommended for adults over age 50, regardless of age or duration of heartburn. Members were divided on whether surveillance prolongs survival, although the majority agreed that it detects curable neoplasia and can be cost-effective in selected patients. The majority did not feel that acid-reduction therapy reduces the risk of esophageal adenocarcinoma but did agree that nonsteroidal antiinflammatory drugs are associated with a cancer risk reduction and are of promising (but unproven) value. Participants rejected the notion that mucosal ablation with acid suppression prevents adenocarcinoma in BE but agreed that this may be an appropriate strategy in a subgroup of patients with high-grade dysplasia.

CONCLUSIONS

Based on this review of BE, the opinions of workshop members on issues pertaining to screening and surveillance are at variance with published clinical guidelines.

A 1 year follow-up study of the consequences of Helicobacter pylori eradication in duodenal ulcer patients: unchanged frequency of erosive oesophagitis and decreased prevalence of non-erosive gastro-oesophageal reflux disease

BACKGROUND AND AIM

Discussions concerning the increased incidence of gastro-oesophageal reflux disease (GORD) after Helicobacter pylori eradication continue. In this study we aimed to evaluate the presence of co-existing GORD in (1) duodenal ulcer patients after successful H. pylori eradication, (2) patients with persistent H. pylori infection after attempts at eradication, and (3) controls in whom H. pylori eradication had not been attempted.

METHODS

A prospective study of 255 patients with duodenal ulcer who were assigned to H. pylori eradication or to control treatment (omeprazole for 4 weeks) and followed up for 1 year or until peptic ulcer relapse. GORD was determined in the patients who had reflux oesophagitis on endoscopy at the beginning of the study and/or in patients without reflux oesophagitis if they experienced heartburn and/or regurgitation at least twice a week associated with impairment of daily activities.

RESULTS

The study revealed a significant decrease (from 44.6% to 21.7%; P < 0.001) of patients with GORD at the end of the follow-up among those in whom H. pylori eradication had been successful. There was no significant difference in the frequency of reflux oesophagitis before and after the follow-up regardless of H. pylori status.

CONCLUSIONS

H. pylori eradication did not significantly influence the prevalence and incidence of reflux oesophagitis in patients with duodenal ulcer during a 1 year follow-up period, but there was a significantly lower prevalence of GORD after successful H. pylori eradication, as patients with non-erosive GORD had been cured.

Is esophagoscopy alone sufficient for patients with reflux symptoms?

BACKGROUND

Unsedated esophagoscopy with ultrathin endoscopes is a valuable screening modality for Barrett's esophagus, but the stomach and the duodenum cannot be examined completely with the smallest and best tolerated of these endoscopes. There are no data as to how often disease in the stomach and the duodenum would be missed when using this screening strategy. Our hypothesis is that patients with reflux symptoms, in the absence of daily abdominal pain, nausea, or history of ulcer, were unlikely to have clinically significant gastroduodenal disease.

METHODS

Patients scheduled for upper endoscopy at a single outpatient endoscopy unit in a tertiary referral center were screened. The inclusion criterion was reflux symptoms as the primary indication for upper endoscopy. Patients with another valid indication were excluded. A detailed history was recorded and symptom questionnaire completed for each patient before endoscopy; these data were compared with the endoscopy findings.

RESULTS

A total of 175 patients were included. Indications for upper endoscopy were the following: worsening symptoms (n=74), ongoing reflux despite therapy (n=27), and long-standing reflux (n=74). Major esophageal findings were discovered in 95 patients. In 10 patients, major gastric or duodenal findings were detected as follows: erosive gastritis (n=8), gastric ulcer (n=2), duodenal ulcer (n=2), erosive duodenitis (n=2), and duodenal polyp (n=1). Daily abdominal pain (p=0.014) or possibly daily nausea (p=0.028 unadjusted, 0.197 adjusted) was associated with major gastric/duodenal disease. Patients without daily abdominal pain, nausea, or a history of gastric/duodenal ulcer were much less likely to have major disease (0.9%) than patients with one of these predictors (13.2%, p=0.00097).

CONCLUSIONS

Daily abdominal pain and nausea, in combination with a history of ulcer disease, are strong predictors of major gastric or duodenal disease. Patients with reflux without these predictors are highly unlikely to have a major disease involving the stomach or duodenum, and are suitable candidates for esophagoscopy alone.

Audit of a Barrett's epithelium surveillance database

BACKGROUND

Barrett's epithelium is a premalignant condition in which endoscopic surveillance is recommended but remains contentious.

AIM

To audit our Barrett's epithelium surveillance database and to calculate the incidence and natural history of dysplasia and cancer in this cohort.

METHODS

A retrospective analysis of a computerised database of patients with columnar lined oesophagus containing specialised intestinal metaplasia was undertaken over a 5-year period. The surveillance protocol was annual endoscopy with 2-cm interval quadrantic biopsies with patients on continuous acid-suppression therapy.

RESULTS

A total of 138 (102 men) patients underwent active surveillance. The mean age was 62.1 years and the mean Barrett's epithelium length was 5.9 cm. Ten patients had low-grade dysplasia, with a mean age of 73.5 years, a mean Barrett's epithelium length of 7.8 cm, a prevalence of 7.2% over 5 years and an incidence of 1.4% per annum. Low-grade dysplasia regressed in five patients, persisted in four patients, and was associated with a concurrent squamous carcinoma in one patient. Three patients had high-grade dysplasia at index endoscopy, with no incident cases. One progressed to adenocarcinoma after 2 years. A cancer incidence of one per 202 patient-years of surveillance was found, equivalent to 0.5% per year.

CONCLUSION

Short-interval (1-year) endoscopic surveillance of Barrett's epithelium offers little reward. Low-grade dysplasia is uncommon, and no progression to adenocarcinoma was seen in this cohort. No incident high-grade dysplasia was observed. Prospective evaluation of a longer endoscopic surveillance interval in controlled clinical studies is warranted.

Mucin core peptide expression can help differentiate Barrett's esophagus from intestinal metaplasia of the stomach

It is important to distinguish Barrett's esophagus (BE) from intestinal metaplasia related to carditis because these conditions have a different natural history, risk of malignancy, and treatment. However, the distinction between these entities is difficult both clinically and pathologically. The aim of this study was to evaluate and compare the immunostaining pattern of five mucin core polypeptides in BE to cases of carditis or antritis with intestinal metaplasia. Routinely processed mucosal biopsies from 22 patients with intestinal-type BE, 24 patients with cardia intestinal metaplasia (10 Helicobacter pylori positive), 17 patients with antral intestinal metaplasia (all H. pylori positive), 20 control patients with a normal antrum, and 22 control patients with a normal cardia were immunostained with monoclonal antibodies against MUC1, MUC2, MUC3, MUC5AC, and MUC6 mucin core polypeptides. Staining was evaluated separately for goblet cells and non-goblet columnar cells and compared between all groups. A significantly higher number of BE cases (P < 0.05) showed goblet cell staining for MUC1 (55%) or MUC6 (32%) compared with patients with carditis with intestinal metaplasia (MUC1 14%, MUC6 7%) or antritis with intestinal metaplasia (MUC1 6%, MUC6 0%). BE also showed a higher frequency of MUC1 and MUC6 positivity in non-goblet columnar cells compared with carditis and antritis cases with intestinal metaplasia. Only cases of BE showed combined MUC1 and MUC6 staining (sensitivity 23%, specificity 100%). The sensitivity and specificity of MUC1 staining for BE are 55% and 96%, respectively, and for MUC6 staining 30% and 96%, respectively. Interestingly, normal gastric cardia mucosa also showed a significantly higher prevalence of MUC2 and MUC3 expression in glandular epithelium (29% and 38%, respectively) compared with the antrum (0% for both markers) (P < 0.05). In conclusion, MUC1 and MUC6 expression in BE is distinct from that of the cardia and antrum with intestinal metaplasia; thus, immunophenotyping for these markers may have some value in a subset of patients in helping to separate BE from patients with intestinal metaplasia of the cardia. Columnar epithelium in the "normal" gastric cardia has a partially intestinalized phenotype and, as a result, may represent an early form of metaplastic epithelium.

Hepatocyte antigen as a marker of intestinal metaplasia

Intestinal metaplasia is a histologic hallmark of Barrett's esophagus and chronic gastritis. Intestinal metaplasia may progress to dysplasia or carcinomas without proper treatment. Most cases of intestinal metaplasia are easily recognized on hematoxylin and eosin-stained sections. However, some cases of intestinal metaplasia may be hard to recognize if they lack the characteristic mucin-producing cells and Paneth cells, or if they are small in size. Recently, keratin 7, keratin 20, and MUC2 expression patterns were reported to be useful in confirming the diagnosis of intestinal metaplasia. We studied hepatocyte (Hep) antigen (a hepatocellular antigen mainly expressing in normal and neoplastic hepatic tissues) in 33 cases of Barrett's esophagus (9 cases associated with esophageal adenocarcinoma) and 13 cases of chronic gastritis associated with intestinal metaplasia and gastric adenocarcinoma. Hep monoclonal antibody recognizes intestinal metaplasia in all cases. We also compared expression of Hep with that of keratin 7, keratin 20, and MUC2 in intestinal metaplasia. The specificity and sensitivity of Hep for intestinal metaplasia were higher than that of keratin 7 and keratin 20, or MUC2. We conclude that Hep may be used as a single diagnostic marker for intestinal metaplasia.

Endoscopic surveillance practice for Barrett' s oesophagus in Scotland and early experience in implementing local guidelines

Management of columnar lined oesophagus (CLO; Barrett s oesophagus) is controversial. We prospectively audited surveillance practices in Scotland and prospectively assessed the impact of introducing local guidelines for Barrett s surveillance in Edinburgh. Most respondents were gastroenterologists. The majority take random, not four quadrant, biopsies from the CLO. In Edinburgh during 2000, 80 patients underwent surveillance. The guideline protocol was not followed in 30 (37.5%) patients. Follow up of patients without dysplasia generally conformed to the guidelines. Follow up of patients with low grade dysplasia was highly variable while management of those with high grade dysplasia followed the guidelines. Overall we found a wide variability in the management and surveillance of CLO. Early experience suggests that implementation of guidelines is helpful but there is still variation in practice.

Histology of Barrett's esophagus and dysplasia

This article explores issues related to the diagnosis of Barrett's esophagus (BE) in endoscopic biopsies and dysplasia in Barrett's epithelium. The definitions of BE, including long- and short-segment BE, are reviewed, with an emphasis on the significance of intestinal metaplasia (IM). IM of the gastroesophageal junction and cardia is reviewed and problems in its distinction from short-segment BE are discussed. In addition, the article reviews the classification of dysplasia in Barrett's mucosa, with reference to problematic areas, such as sampling error and interobserver variability. Biomarkers and their role in the diagnosis of dysplasia and stratification of risk are summarized.

Does methylene blue detect intestinal metaplasia in Barrett's esophagus?

BACKGROUND

Methylene blue has been used to selectively stain areas of specialized intestinal metaplasia in Barrett's esophagus. The sensitivity, specificity, and negative and positive predictive values for the detection of specialized intestinal metaplasia by methylene blue chromoendoscopy were determined in patients with Barrett's esophagus.

METHODS

Thirty patients with Barrett's esophagus underwent endoscopy with biopsy specimens obtained from areas that stained positive and negative with methylene blue. Histopathologic findings were compared with methylene blue chromoendoscopy findings.

RESULTS

Two hundred ninety-two biopsy specimens (mean 9.7/patient) were obtained: 203 from stained and 89 from unstained areas. Sensitivity, specificity, and negative and positive predictive values for detection of specialized intestinal metaplasia were, respectively, 72%, 46%, 22%, and 89%. Comparing 187 biopsy specimens from patients with long-segment Barrett's esophagus with 105 specimens from patients with short-segment Barrett's esophagus, the sensitivity, specificity, and negative and positive predictive values were, respectively, 77% versus 63% (p = 0.044), 79% versus 21% (p < 0.002), 28% versus 14% (p = 0.219), and 97% versus 73% (p < 0.002). The odds ratio for detection of specialized intestinal metaplasia in stained areas was 12.40 in long-segment and 0.45 in short-segment Barrett's esophagus.

CONCLUSIONS

Data from this study confirm the value of methylene blue chromoendoscopy for detection of specialized intestinal metaplasia in long-segment Barrett's esophagus, but not in short-segment Barrett's esophagus.

Surveillance in Barrett's oesophagus: a personal view

Barrett's oesophagus is defined as columnar-lined oesophagus of any length containing specialised intestinal metaplasia. Diagnosis depends on close corroboration between the endoscopist and histopathologist. It occurs in 10% of patients presenting endoscopically with reflux symptoms and has an adenocarcinoma incidence of 0.4% to 2%. Surveillance is performed to detect precancerous change (dysplasia) and early stage disease has a good surgical prognosis. Computer models suggest cost efficacy comparable to other health measures. However most patients with Barrett's do not die of oesophageal cancer and elective oesophagectomy has an appreciable mortality. Endoscopic ablation techniques and improved definition of high risk subgroups will help shape future surveillance programmes.

Barrett's esophagus

Barrett's esophagus is an acquired condition resulting from severe esophageal mucosal injury. It still remains unclear why some patients with gastroesophageal reflux disease develop Barrett's esophagus whereas others do not. The diagnosis of Barrett's esophagus is established if the squamocolumnar junction is displaced proximal to the gastroesophageal junction and if intestinal metaplasia is detected by biopsy. Despite this seemingly simple definition, diagnostic inconsistencies remain a problem, especially in distinguishing short segment Barrett's esophagus from intestinal metaplasia of the gastric cardia. Barrett's esophagus would be of little importance were it not for its well-recognized association with adenocarcinoma of the esophagus. The incidence of esophageal adenocarcinoma continues to increase and the 5-year survival rate for this cancer remains dismal. However, cancer risk for a given patient with Barrett's esophagus is lower than previously estimated. Current strategies for improved survival in patients with esophageal adenocarcinoma focus on cancer detection at an early and potentially curable stage. This can be accomplished either by screening more patients for Barrett's esophagus or with endoscopic surveillance of patients with known Barrett's esophagus. Current screening and surveillance strategies are inherently expensive and inefficient. New techniques to improve the efficiency of cancer surveillance are evolving rapidly and hold the promise to change clinical practice in the future. Treatment options include aggressive acid suppression, antireflux surgery, chemoprevention, and ablation therapy, but there is still no clear consensus on the optimal treatment for these patients.

Role of acid and bile reflux in development of specialised intestinal metaplasia in distal oesophagus

BACKGROUND

Barrett's oesophagus is defined as specialised intestinal metaplasia in the distal oesophagus, regardless of extension.

AIM

To study distal oesophagus function, and acid and bile exposure in patients with Long Segment (>3 cm), Short Segment (1 to 2 cm) and Ultra-short Segment (<1 cm) Barrett's Oesophagus, and in patients with gastro-oesophageal reflux disease without intestinal metaplasia.

PATIENTS

Study population comprised 17 patients with Long, 8 with Short, 9 with Ultra-Short Segment Barrett's oesophagus, 32 with reflux disease and 12 healthy volunteers.

METHODS

Patients were evaluated by manometry and by 24-hour pH and bile monitoring.

RESULTS

Patients with intestinal metaplasia had greater acid exposure of the distal oesophagus than healthy volunteers. Patients with Long Segment Barrett's oesophagus had a longer history of symptoms, worse lower oesophageal sphincter pressures and longer bile and acid exposure than the other patients. Long Segment Barrett's oesophagus was predicted by low oesophageal pressure and increased bile exposure, age and male sex.

CONCLUSION

Acid exposure in the distal oesophagus is probably the aetiological factor behind intestinal metaplasia, but a severely damaged antireflux barrier and bile in the refluxate are necessary for Long Segment Barrett's Oesophagus to develop.