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Romańczyk M, Budzyń K, Romańczyk T, Lesińska M, Koziej M, Hartleb M, Waluga M. Heterotopic Gastric Mucosa in the Proximal Esophagus: Prospective Study and Systematic Review on Relationships with Endoscopic Findings and Clinical Data. Dysphagia 2023; 38:629-640. [PMID: 35809096 DOI: 10.1007/s00455-022-10492-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Accepted: 06/23/2022] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Marcin Romańczyk
- Endoterapia, H-T. Centrum Medyczne, Aleja Bielska 105, 43-100, Tychy, Poland
- Chair and Department of Gastroenterology and Hepatology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Krzysztof Budzyń
- Endoterapia, H-T. Centrum Medyczne, Aleja Bielska 105, 43-100, Tychy, Poland.
- Chair and Department of Gastroenterology and Hepatology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland.
| | - Tomasz Romańczyk
- Endoterapia, H-T. Centrum Medyczne, Aleja Bielska 105, 43-100, Tychy, Poland
- Department of Gastroenterology, Wyższa Szkoła Techniczna W Katowicach, Katowice, Poland
| | - Magdalena Lesińska
- Endoterapia, H-T. Centrum Medyczne, Aleja Bielska 105, 43-100, Tychy, Poland
- Department of Gastroenterology, Wyższa Szkoła Techniczna W Katowicach, Katowice, Poland
| | - Mateusz Koziej
- Department of Anatomy, Jagiellonian University Medical College, Krakow, Poland
| | - Marek Hartleb
- Chair and Department of Gastroenterology and Hepatology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Marek Waluga
- Endoterapia, H-T. Centrum Medyczne, Aleja Bielska 105, 43-100, Tychy, Poland
- Chair and Department of Gastroenterology and Hepatology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
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Ito M, Dobashi A, Komori M, Sugimura S, Aizawa D, Takahashi K, Tanishima Y, Sumiyama K. Lymph node metastasis after endoscopic submucosal dissection of a superficial esophageal adenocarcinoma arising from the ectopic gastric mucosa of the cervical esophagus: A case report. DEN OPEN 2023; 3:e214. [PMID: 36825033 PMCID: PMC9942940 DOI: 10.1002/deo2.214] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 01/17/2023] [Accepted: 02/04/2023] [Indexed: 02/25/2023]
Abstract
Esophageal adenocarcinoma derived from the ectopic gastric mucosa of the cervical esophagus is very rare. Little is known about the efficacy of endoscopic treatment of these superficial lesions. Herein, we report the first case of lymph node metastasis after endoscopic submucosal dissection of a lesion with invasion into the muscularis mucosa. A 46-year-old man underwent esophagogastroduodenoscopy during a health checkup. Endoscopy revealed a 10-mm-sized nodular and a 5-mm-sized depressed lesion within the ectopic gastric mucosa of the cervical esophagus. The biopsy specimen confirmed the presence of adenocarcinoma. The entire ectopic gastric mucosa was resected by endoscopic submucosal dissection, and pathological examination showed invasion of the muscularis mucosa. A follow-up computed tomography scan revealed lymph node metastasis 12 months post-treatment. The patient underwent surgical mediastinal lymphadenectomy. The patient has been regularly followed up with a computed tomography scan and endoscopy for 2 years post-surgery with no evidence of recurrence. Close follow-up or additional treatment after endoscopic submucosal dissection should be considered and discussed with the patient if invasion into the muscularis mucosa is observed on pathological examination.
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Affiliation(s)
- Mamoru Ito
- Department of EndoscopyThe Jikei University School of MedicineTokyoJapan
| | - Akira Dobashi
- Department of EndoscopyThe Jikei University School of MedicineTokyoJapan
| | - Moe Komori
- Department of Gastroenterology and HepatologyThe Jikei University School of MedicineTokyoJapan
| | - Shun Sugimura
- Department of Gastroenterology and HepatologyThe Jikei University School of MedicineTokyoJapan
| | - Daisuke Aizawa
- Department of PathologyThe Jikei University School of MedicineTokyoJapan
| | - Keita Takahashi
- Department of SurgeryThe Jikei University School of MedicineTokyoJapan
| | | | - Kazuki Sumiyama
- Department of EndoscopyThe Jikei University School of MedicineTokyoJapan
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Yin Y, Li H, Feng J, Zheng K, Yoshida E, Wang L, Wu Y, Guo X, Shao X, Qi X. Prevalence and Clinical and Endoscopic Characteristics of Cervical Inlet Patch (Heterotopic Gastric Mucosa): A Systematic Review and Meta-Analysis. J Clin Gastroenterol 2022; 56:e250-e262. [PMID: 33780217 DOI: 10.1097/mcg.0000000000001516] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 01/26/2021] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Yue Yin
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang
- Postgraduate College, Jinzhou Medical University, Jinzhou
| | - Hongyu Li
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang
| | - Ji Feng
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang
| | - Kexin Zheng
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang
- Postgraduate College, Jinzhou Medical University, Jinzhou
| | - Eric Yoshida
- Department of Medicine, Division of Gastroenterology, Vancouver General Hospital, Vancouver, Canada
| | - Le Wang
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang
- Postgraduate College, Dalian Medical University, Dalian, People's Republic of China
| | - Yanyan Wu
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang
- Postgraduate College, Jinzhou Medical University, Jinzhou
| | - Xiaozhong Guo
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang
| | - Xiaodong Shao
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang
| | - Xingshun Qi
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang
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Romańczyk M, Romańczyk T, Lesińska M, Romańczyk A, Hartleb M, Waluga M. Influence of narrow-band imaging (NBI) and enhanced operator's attention during esophagus inspection on cervical inlet patches detection. Adv Med Sci 2021; 66:170-175. [PMID: 33640715 DOI: 10.1016/j.advms.2021.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 01/14/2021] [Accepted: 02/10/2021] [Indexed: 02/07/2023]
Abstract
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 (NBIEA, 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.
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Sato H, Takeuchi M, Terai S. Endoscopic diverticulectomy for Zenker's diverticulum with heterotopic gastric mucosa. Dig Endosc 2020; 32:145. [PMID: 31529715 DOI: 10.1111/den.13529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Hiroki Sato
- Division of Gastroenterology, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Manabu Takeuchi
- Division of Gastroenterology, Nagaoka Red Cross Hospital, Niigata, Japan
| | - Shuji Terai
- Division of Gastroenterology, Niigata University Medical and Dental Hospital, Niigata, Japan
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Abstract
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.
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Rusu R, Ishaq S, Wong T, Dunn JM. Cervical inlet patch: new insights into diagnosis and endoscopic therapy. Frontline Gastroenterol 2018; 9:214-220. [PMID: 30046427 PMCID: PMC6056090 DOI: 10.1136/flgastro-2017-100855] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 09/25/2017] [Accepted: 10/18/2017] [Indexed: 02/04/2023] Open
Abstract
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.
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Affiliation(s)
- Radu Rusu
- Department of Gastroenterology, Guy's & St Thomas' Hospitals NHS Foundation Trust, London, UK
| | - Sauid Ishaq
- Department of Gastroenterology, Russells Hall Hospital, Birmingham City University, Birmingham, UK
| | - Terry Wong
- Department of Gastroenterology, Guy's & St Thomas' Hospitals NHS Foundation Trust, London, UK
| | - Jason M Dunn
- Department of Gastroenterology, Guy's & St Thomas' Hospitals NHS Foundation Trust, London, UK
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Yamada T, Tsuji A, Onoue S, Kaneko M, Tanioka F, Osawa S, Saida Y. Acid suppressive therapy improved symptoms due to circumferential cervical inlet patch with proton pumps (H +/K +-ATPase). World J Clin Cases 2017; 5:403-406. [PMID: 29204429 PMCID: PMC5700390 DOI: 10.12998/wjcc.v5.i11.403] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 08/25/2017] [Accepted: 09/13/2017] [Indexed: 02/05/2023] Open
Abstract
Cervical inlet patch (CIP), also referred to as esophageal heterotopic gastric mucosa, is regarded as the residue of columnar epithelium of the embryonic esophagus. Narrow band imaging increases the detection rate of CIP. Herein, we present a 55-year-old man with symptomatic circumferential inlet patch. He exhibited globus and dysphagia, and esophagogastroduodenoscopy found cir-cumferential CIP, where im-munohistochemistry revealed the existence of pro-ton pumps (H+, K+-ATPase). His throat symptoms were relieved by acid suppressive therapy with pump inhibitors. This case indicated that CIP should be considered as a differential diagnosis for the cause of globus symptoms in rare cases.
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Affiliation(s)
- Takanori Yamada
- Department of Gastroenterology, Iwata City Hospital, Iwata 438-8550, Japan
| | - Atsushi Tsuji
- Department of Gastroenterology, Iwata City Hospital, Iwata 438-8550, Japan
| | - Shunya Onoue
- Department of Gastroenterology, Iwata City Hospital, Iwata 438-8550, Japan
| | - Masanao Kaneko
- Department of Gastroenterology, Iwata City Hospital, Iwata 438-8550, Japan
| | - Fumihiko Tanioka
- Division of Pathology, Iwata City Hospital, Iwata 438-8550, Japan
| | - Satoshi Osawa
- Department of Endoscopic and Photodynamic Medicine, Hamamatsu University School of Medicine, Hamamatsu 431-3192, Japan
| | - Yasuhiko Saida
- Department of Gastroenterology, Iwata City Hospital, Iwata 438-8550, Japan
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Peitz U, Vieth M, Evert M, Arand J, Roessner A, Malfertheiner P. The prevalence of gastric heterotopia of the proximal esophagus is underestimated, but preneoplasia is rare - correlation with Barrett's esophagus. BMC Gastroenterol 2017; 17:87. [PMID: 28701149 PMCID: PMC5508702 DOI: 10.1186/s12876-017-0644-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Accepted: 07/02/2017] [Indexed: 02/07/2023] Open
Abstract
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.
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Affiliation(s)
- Ulrich Peitz
- Clinic of Gastroenterology, Hepatology, and Infectious Diseases, Otto-von-Guericke University, Leipziger Str. 44, D 30120, Magdeburg, Germany. .,Clinic of Gastroenterology, Raphaelsklinik, Münster, Germany.
| | - Michael Vieth
- Institute of Pathology, Klinikum Bayreuth, Bayreuth, Germany
| | - Matthias Evert
- Institute of Pathology, University Regensburg, Regensburg, Germany
| | - Jovana Arand
- Clinic of Gastroenterology, Hepatology, and Infectious Diseases, Otto-von-Guericke University, Leipziger Str. 44, D 30120, Magdeburg, Germany
| | - Albert Roessner
- Institute of Pathology, Otto-von-Guericke University, Magdeburg, Germany
| | - Peter Malfertheiner
- Clinic of Gastroenterology, Hepatology, and Infectious Diseases, Otto-von-Guericke University, Leipziger Str. 44, D 30120, Magdeburg, Germany
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Kadota T, Fujii S, Oono Y, Imajoh M, Yano T, Kaneko K. Adenocarcinoma arising from heterotopic gastric mucosa in the cervical esophagus and upper thoracic esophagus: two case reports and literature review. Expert Rev Gastroenterol Hepatol 2016; 10:405-14. [PMID: 26610162 DOI: 10.1586/17474124.2016.1125780] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
- Tomohiro Kadota
- a Department of Gastroenterology, Endoscopy Division , National Cancer Center Hospital East , Kashiwa , Japan
| | - Satoshi Fujii
- b Pathology Division, Research Center for Innovative Oncology , National Cancer Center Hospital East , Kashiwa , Japan
| | - Yasuhiro Oono
- a Department of Gastroenterology, Endoscopy Division , National Cancer Center Hospital East , Kashiwa , Japan
| | - Maomi Imajoh
- a Department of Gastroenterology, Endoscopy Division , National Cancer Center Hospital East , Kashiwa , Japan
| | - Tomonori Yano
- a Department of Gastroenterology, Endoscopy Division , National Cancer Center Hospital East , Kashiwa , Japan
| | - Kazuhiro Kaneko
- a Department of Gastroenterology, Endoscopy Division , National Cancer Center Hospital East , Kashiwa , Japan
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