Primary Motility  Disorders of the  Esophagus
 The Esophageal
 Mucosa
 The
 Esophagogastric  Junction
 Barrett's
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OESO©2015
 
Volume: The Esophageal Mucosa
Chapter: Ulcers in CLE
 

What is termed a Savary's ulcer? How does the evolution of a typical Barrett's ulcer differ from that of a Savary's ulcer?

E. Brossard, J.B. Ollyo, C. Fontolliet, M. Savary, Ph. Monnier (Lausanne)

In subjects with Barrett's esophagus, esophageal ulcers are situated either within the metaplastic columnar mucosa in the lower part of the esophagus (Barrett's ulcer), or

0222F1.JPG

Figure I. .Barrett's and Savary's ulcers.

higher up in the malpighian region (Savary's ulcer) [1,2] (Fig. 1). Some authors have suggested that Barrett's ulcer is caused by a local secretion of acid by the heterotopic columnar epithelium in the lower part of the esophagus [3]. This etiopathogenesis of Barrett's ulcer is now strongly contested. In 1966, Savary described a junctional peptic ulcer localized on the squamous cell lining, at the upper pole of Barrett's mucosa. This ulcer, known as Savary's ulcer by his students, is thought to be caused by pathological gastroesophageal reflux (GER). Endoscopically, it is characterized by an oval shaped loss of substance, orientated longitudinally, with sharp edges and a crater, whose depth depends on the age of the lesion. This definition excludes superficial ulceration or erosion and all lesions involving diffuse loss of substance over the whole circumference of the esophagus.

Patients and Method

In order to define the differences between Barrett's ulcer and Savary's ulcer, we examined the endoscopic case records of the Centre Hospitalier Universitaire Vaudois in Lausanne over a period of 27 years (from 1963 to 1990). During this period, 44,203 esophagoscopies were carried out. Barrett's esophagus was found in 448 cases. Barrett's ulcer was diagnosed in 50 cases, and Savary's ulcer in 37 cases. Savary's ulcer and Barrett's ulcer were both present in five cases. The prevalence of ulcers in patients with Barrett's esophagus was 20.5%. No significant difference was observed between patients with Savary's ulcer and those with Barrett's ulcer with regard to mean age. In contrast, there was a clear predominance of males among the patients with Barrett's ulcer, and a predominance of females among those with Savary's ulcer (Table 1).

Table 1..

Barrett's ulcer (n = 50)

Savary 's ulcer (n = 37)

Age (years)

- mean

67

63.7

- range

3-85

33-85

Sex

-Male

72%

43%

- Female

38%

57%

Results

Three quarters of the patients with Savary's or Barrett's ulcer had characteristic and chronic (> 5 years) symptoms of GER. Evident gastrointestinal bleeding or anemia of spoliative type was observed in 40% of patients with Savary's ulcer and 72% of patients with Barrett's ulcer. Among the endoscopic characteristics of these two types of ulcer associated with Barrett's esophagus, there was no significant difference with regard to size, and length of Barrett's esophagus and the frequency of concomitant erosive esophagitis. Savary's ulcer differed from Barrett's ulcer by the fact that it was frequently associated with peptic stenosis (Table 2). Biopsies of the rims of Barrett's ulcer revealed a squamous epithelium in 20% of cases. Two patients developed a Barrett's ulcer at a site where 17 and 105 months earlier there had been a large islet of epidermoid mucosa. In 14 cases, repeated endoscopic examinations made it possible to follow the progress of erosive and ulcerative esophagitis of the squamous mucosa into an ulcer surrounded by a columnar mucosa (Barrett's ulcer). These observations argue in favor of a peptic origin of Barrett's ulcer through pathological GER. The vast majority of these ulcers associated with Barrett's esophagus were medically treated, mainly because of the advanced age of the patients. Among the patients who were followed up, the majority of ulcers were healed through medical treatment. There was, however, a significant recurrence rate of ulcers or esophagitis in patients with Savary's ulcer (Table 3). Ninety percent of the 18 patients who underwent antireflux surgery and long-term follow-up were healed. Surgery is consequently the treatment of choice for Savary's and Barrett's ulcers.

Table 2. .Endoscopic characteristics

Barrett's ulcer (n = 50)

Savary's ulcer (n = 37)

Size (cm)

0.5-5

0.5-2

Length of Barrett's esophagus (cm)

- mean

7

4.5

- range

3-13

3-10

Erosive esophagitis

34 (68%)

27 (73%)

Peptic stenosis

16 (32%)

25 (67%)

Table 3. .Medical treatment

Barrett's ulcer (32/50)

Savary's ulcer (23/37)

Patients followed up

18

15

Follow-up (months)

- mean

37

52

- range

6-69

6-107

Healed

15 (83%)

14 (93%)

Recurrence of ulcer or esophagitis

5 (28%)

7 (46%)

Discussion

In our opinion, Barrett's ulcer and Savary's ulcer are a complication of GER [4]. In practice, the patient's history almost always reveals typical symptoms of GER. The fact that an acid-secreting mucosa is rarely found in biopsy material collected from areas close to the Barrett's ulcer and that these ulcers commonly heal after antireflux surgery, also argues in favor of a peptic origin of ulcers associated with Barrett's esophagus [5].

In addition, endoscopy has shown that Savary's ulcer, like Barrett's ulcer, is usually associated with other classical lesions of GER (junctional peptic stenosis and/or erosion) [6].

Conclusion

Gastroesophageal reflux can cause two types of ulcers in patients with Barrett's esophagus. Savary's ulcer differs from Barrett's ulcer in its location at the squamo-columnar junction, and by the fact that it is associated with peptic stenosis in 60% of cases. It predominates in elderly women and rarely bleeds. Savary's ulcer frequently recurs after medical treatment, and the treatment of choice is antireflux surgery.

References

1. Ollyo JB, Monnier Ph, Fontolliet Ch, Birchler R, Fasel J, Levi F, Gonvers JJ. L'ulcère de Savary: une nouvelle complication du reflux gastro-oesophagien. Schweiz Med Wochenschr 1988;118(2l):823-827.

2. Barrett NR. Chronic peptic ulcer of the oesophagus and oesophagitis. Br J Surg 1950;38:175-182.

3. Ustach TJ, Tobon F, Schuster MM. Demonstration of acid secretion from oesophageal mucosa in Barrett's ulcer. Gatrointest Endosc 1988:16:98-100.

4. Ollyo JB, Fontolliet Ch, Monnier Ph, Bauerfeind P, Ciluffo T, Gonvers JJ, Savary M. Hetirogeniite palhogenique des ulcères de Barrett. Schweiz Med Wochenschr 1989;119(21):747-751.

5. Ollyo JB, Fontolliet Ch, Wellinger J, Brossard E, Levi F, Monnier Ph Peptic ulcers of the esophagus are not a complication of Barrett's epithelium. Acta Endoscopica 1991;21:68l-692.

6. Adler RM. The lower esophagus lined columnar epithelium. J Thorac Cardiovasc Surg 1963:45:13-34.


Publication date: May 1994 OESO©2015