Understanding the Columnar Lined Esophagus and Its Variations in Length With Age: A Cadaveric Study

Introduction Columnar lined epithelium (CLE) of the esophagus holds particular importance in diagnosing Barrett's esophagus (BE). In Asia, the prevalence of BE ranges from 0.06% to 6.2%. In India, prevalence estimates vary from 2.6% to 23%. The frequency of esophageal adenocarcinoma has also been observed to be increasing alarmingly over the past few decades. The length of CLE as a criterion for diagnosing BE is the subject of considerable debate. Changes in CLE length among different age groups may exist. Our study aims to measure the length of CLE, or the distance between the angle of His and the Z Line (AZ distance), in normal individuals from Northeast India, and to analyze its variation across different age groups. Materials and methods The study was conducted in the Department of Anatomy and the Department of Forensic Medicine and Toxicology at Gauhati Medical College, Guwahati, Assam, India, during the period 2017-2019. Once opened, each specimen was laid flat on a board. The distance between the A and Z lines was measured using a pair of vernier calipers. This distance was recorded as the AZ distance in millimeters (mm). Results The mean AZ Distance was found to be 12.4 ± 5.3 mm. A significant correlation between age and AZ distance was observed. Conclusion Our present study suggests that the length of the CLE increases with age. This observation offers an opportunity to revisit or revise the diagnostic criteria based on CLE length, taking into account the age of the individual.

Presence or absence of intestinal metaplasia but not its burden is associated with prevalent high-grade dysplasia and cancer in Barrett's esophagus

Universal agreement on the inclusion of intestinal metaplasia to diagnose Barrett's esophagus (BE) is lacking. Our aim was to determine the association of intestinal metaplasia and its density with the prevalence of dysplasia/cancer in columnar lined esophagus (CLE). Patients with CLE but no intestinal metaplasia (CLE-no IM) were identified by querying the clinical pathology database using SNOMED codes for distal esophageal biopsies. CLE-IM patients were identified from a prospectively maintained database of BE patients. Subsequently, relative risks for prevalent dysplasia and cancer were calculated. Since patients with CLE-no IM are not usually enrolled in surveillance, only prevalent dysplasia/cancer on index endoscopy was analyzed. Goblet cell density and percent intestinal metaplasia were estimated. All biopsy slides were reviewed for dysplasia by two experienced gastrointestinal pathologists. Two hundred sixty-two CLE-IM and 260 CLE-no IM patients were included (age 64±12 vs. 60±11 years, P=0.001; whites 92% vs. 82%, P=0.001; males 99.7% vs. 99.3%, P=NS; CLE length 3.4±3.2 vears 1.4±0.4 cm, P=0.001 and hiatus hernia 64% vs. 56%, P=0.013). The odds of finding low-grade dysplasia and of high-grade dysplasia (HGD)/cancer were 12.5-fold (2.9-53.8, P=0.007) and 4.2-fold (95% CI 1.4-13, P=0.01) higher, respectively, in the CLE-IM group. Reanalysis after controlling for important variables of age, race, and length did not significantly alter the overall results. In CLE-IM group, when patients with high (>50/LPF) versus low goblet cell density (<50/LPF) and <10% versus >10% intestinal metaplasia were compared, the odds of HGD/cancer, OR 1.5 (0.5-4.9, P=0.5) and 1.97 (0.54-7.22), respectively, were not significantly higher. Demonstration of intestinal metaplasia continues to be an essential element in the definition of BE, but its quantification may not be useful for risk stratification of HGD/cancer in BE.