Ectopic gastric mucosa in the upper esophagus: detection and radiographic findings

Clinical evaluation of twenty cases of heterotopic gastric mucosa of upper esophagus during five-year observation, using gastroscopy in combination with histopathological and microbiological analysis of biopsies

Aim of the study

Heterotopic gastric mucosa of the upper esophagus (HGMUE) may be connected with disorders of the upper gastrointestinal tract, exacerbated by Helicobacter pylori. Furthermore, HGMUE may be the origin of malignant progression to cervical esophageal carcinoma.

Material and methods

In this work, 20 patients with diagnosed heterotopic gastric mucosa of the upper esophagus (HGMUE) were subjected to 5-year follow-up to determine the extent and structure of histopathological changes within HGMUEs, as well as HGMUE dysplasia and metaplasia, and risk of their malignant transformation. As a diagnostic tool to describe localization, form, size and surface feature of HGMUEs, endoscopy was used. At the same time, the biopsies were collected for histopathological and microbiological analysis.

Results

In examined patients, HGMUEs were associated with inflammation, chronic gastritis, hiatus hernia, duodenal bulb erosion and ulcer and infection of H. pylori. Intestinal metaplasia and low grade dysplasia were also indicated. During 5 years of observation, both the clinical and histopathological image of diagnosed HGMUEs was stable. The patients with detected presence of H. pylori were treated with triple or quadruple therapy.

These results show that HGMUEs may be associated with severe complications in the gastrointestinal tract, such as infection by H. pylori, hiatus hernia or duodenal ulcer. Although dysplasias and metaplasias found in diagnosed HGMUEs were not very numerous and relatively stable both clinically and histopathologically, at the present stage of the study we cannot exclude the possibility of HGMUE malignant transformation.

Esophageal inlet patch

An inlet patch is a congenital anomaly consisting of ectopic gastric mucosa at or just distal to the upper esophageal sphincter. Most inlet patches are largely asymptomatic, but in problematic cases complications related to acid secretion such as esophagitis, ulcer, web and stricture may occur. The diagnosis of inlet patch is strongly suggested on barium swallow where the most common pattern consists of two small indentations on the wall of the esophagus. The diagnosis of inlet patch is confirmed via endoscopy with biopsy. At endoscopy, the lesion appears salmon-coloured and velvety and is easily distinguished from the normal grey-white squamous epithelium of the esophagus. The prominent margins correlate with the radiological findings of indentations and rim-like shadows on barium swallow. Histopathology provides the definitive diagnosis by demonstrating gastric mucosa adjacent to normal esophageal mucosa. No treatment is required for asymptomatic inlet patches. Symptomatic cases are treated with proton pump inhibitors to relieve symptoms related to acid secretion. Strictures and webs are treated with serial dilatation and should be biopsied to rule out malignancy.

Heterotopic gastric mucosal patch in patients with reflux laryngitis: an entity of clinical interest?

Heterotopic gastric mucosal patch (HGMP) in the upper esophagus has been suggested to play a role in the pathogenesis of laryngopharyngeal reflux. The aim of this study was to evaluate the prevalence and possible clinical significance of HGMPs in patients who underwent laparoscopic Nissen fundoplication for gastroesophageal reflux disease-induced reflux laryngitis.Forty consecutive patients with pH-proven reflux laryngitis referred to surgery by a specialist in otorhinolaryngology underwent laparoscopic Nissen fundoplication between 1998 and 2002. Twenty-seven (67.5%) of these patients underwent a postoperative upper gastrointestinal endoscopy paying special attention for detecting possible HGMPs in the proximal esophagus. When HGMP was found, biopsies were taken for histologic confirmation. A small histologically confirmed HGMP was detected in 1 out of 27 patients (3.7%). The prevalence of HGMPs in the upper esophagus in this specific patient group operated on for gastroesophageal reflux disease-induced reflux laryngitis equals the reported general prevalence rates of HGMPs detected in patients referred for upper gastrointestinal endoscopy as a part of gastrointestinal tract evaluation. The role of at least small HGMPs in the proximal esophagus in the pathogenesis of laryngopharyngeal reflux is clinically insignificant.

Heterotopic gastric mucosa (inlet patch): endoscopic prevalence, histopathological, demographical and clinical characteristics

OBJECTIVE

Heterotopic gastric mucosa (HGM) is found in the cervical oesophagus, just below the upper oesophageal sphincter, and has generally been overlooked by endoscopists. The objective of the present study is to determine endoscopic prevalence and histopathological and clinical characteristics of HGM and to classify patients according to their clinicopathological features.

METHOD

A total of 911 consecutive patients (436 M and 475 F) who were admitted to our Endoscopy Unit were examined. HGM type and the presence of Helicobacter pylori (Hp) either in the stomach or in the HGM were histopathologically evaluated.

RESULTS

Of the 911 patients, 33 (25 M and 8 F) were found to have HGM. HGM prevalence was determined to be 3.6%. On the basis of HGM patients' symptoms, only dysphagia was significantly correlated with the size of HGM (p < 0.05). Hp was positive in 29.2% of HGM. Clinicopathological classification of the patients showed that 20 patients were HGM type 1 and 13 were HGM type 2. None of the patients had HGM type 3, 4 or 5.

CONCLUSION

Prevalence of HGM was 3.6%. Dysphagia was found related with the size of HGM. This may be associated with larger HGMs' causing more acid secretion.

Heterotopic gastric mucosa of the esophagus: literature-review and proposal of a clinicopathologic classification

The prevalence of heterotopic gastric mucosa (HGM) in the cervical esophagus is frequently underestimated. Tiny microscopic foci have to be distinguished from a macroscopically visible patch, also called "inlet patch." Symptoms as well as morphologic changes associated with HGM are regarded as a result of the damaging effect of acid, produced by parietal cells in the mostly fundic type of HGM. We herein review the literature and propose a new clinicopathologic classification of esophageal HGM: Most of the carriers of esophageal HGM are asymptomatic (HGM I). Some individuals with HGM in the esophagus complain of dysphagia, odynophagia, or "extraesophageal manifestations" (hoarseness and coughing), without further morphologic findings (HGM II). Still fewer patients are symptomatic due to morphologic changes, i.e., esophageal strictures, webs, or esophagotracheal fistula (HGM III). Malignant transformation via dysplasia (intraepithelial neoplasia, HGM IV) to cervical esophageal adenocarcinoma (HGM V) is exceedingly rare (only 24 reported cases). In contrast to Barrett's esophagus, HGM should not be regarded as a precancerous lesion. Symptoms are more likely to occur in patients with inlet patch, whereas malignant transformation and adenocarcinogenesis can also occur in microscopic HGM foci. Asymptomatic HGM requires neither specific therapy nor endoscopic surveillance. Only in symptomatic cases treatment, i.e., dilatation for (benign) strictures or acid suppression for reflux symptoms, can be recommended. Patients with low-grade dysplasia in HGM might be candidates for surveillance strategies, whereas in cases of high-grade dysplasia and invasive adenocarcinoma oncological treatment strategies must be employed.

Ectopic gastric mucosa in the cervical esophagus

This study describes the clinical presentation and management of ectopic gastric mucosa (EGM) in the cervical esophagus. This is a case report of a 53-year-old male who presented with left-sided odynophagia of 3 months' duration. Office examination, including flexible fiberoptic laryngoscopy, was unremarkable. Direct larynogoscopy and rigid esophagoscopy revealed a 2 x 1-cm fleshy, red, and raised lesion in the cervical esophagus. The remainder of the esophagus was normal. Histologic examination of a biopsy specimen from the lesion showed a normal gastric epithelium consistent with the diagnosis of ectopic gastric mucosa. He was treated with 3 months of proton pump inhibitors, which resulted in complete symptom resolution. Patient was then switched to H2-blockers and has been symptom-free for one year. The medical literature regarding EGM in the cervical esophagus is reviewed with respect to its incidence, pathogenesis, clinical course, and management. In conclusion, EGM can occur in the cervical esophagus, and odynophagia is the typical presenting symptom. Adenocarcinoma developing within random, nonsyndromic EGM of the cervical esophagus is exceedingly rare. The primary mode of treatment is medical therapy.

Ectopic gastric mucosa in the oesophagus mimicking ulceration

We report two patients with ectopic gastric mucosa in the oesophagus in whom emergency contrast medium studies after traumatic endoscopy revealed broad, flat depressions on the right lateral wall of the upper oesophagus that could initially be mistaken for ulcers or even intramural dissections. However, the appearance and location of these lesions is so characteristic of ectopic gastric mucosa that confirmation with endoscopic biopsy specimens probably is not required in asymptomatic patients.

Symptomatic heterotopic gastric mucosa in the upper oesophagus

The presence of heterotopic gastric mucosa in the upper oesophagus has been reported to occur in up to 10 per cent of individuals but it is usually asymptomatic. We present two patients with symptomatic oesophageal heterotopic gastric mucosa and discuss the aetiology, pathogenesis, and management of the condition.