Primary Motility  Disorders of the  Esophagus
 The Esophageal
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 Esophagogastric  Junction
 Barrett's
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OESO©2015
 
Volume: The Esophagogastric Junction
Chapter: Esophageal columnar metaplasia (Barrett s esophagus)
 

What is the value of radionuclide scanning in the surveillance of patients with Barrett's esophagus?

E.M. Smith, K.H. Gladden, S. Fink, T.K. Chaudhuri (Hampton)

Barrett's esophagus (BE) is an acquired condition in which reflux of gastric and duodenal contents results in columnar epithelial replacement of the normal squamous mucosa of the lower esophagus [1, 2]. BE has a malignant potential, since the progression from squamous epithelium to Barrett's metaplasia continues to invasive esophageal carcinoma in a subgroup of patients [3, 4]. Prevalence rates for BE range from 8-15%, although some reports approach 20% in the general population [5] and 50% in patients with gastroesophageal reflux disease [6]. The incidence of adenocarcinoma of the esophagus is rising worldwide [7] and the incidence rate of cancer development in patients with BE ranges from one adenocarcinoma per 46 to one per 441 patient year follow-up. This may also be expressed as representing a 30 to 125-fold increased risk for esophageal cancer over that of the general population [8, 9]. This evolution takes at least two years, with the vast majority of BE patients never progressing past normal mucosa or low-grade dysplasia [10]. These data have raised the question of how best to survey patients with BE, so that their chance of early cancer diagnosis may be maximized [8, 11].

Surveillance techniques

Radiologic technique

The double-contrast barium esophagogram represents the most readily available means to evaluate BE. Few patients with BE will have normal radiologic findings, but many patients are not referred for radiologic examination because the procedure may fail to demonstrate uncomplicated mucosal dysplasia in up to 60% of patients with BE [12]. The presence of midesophageal stricture, mucosal reticular pattern and deep esophageal ulceration suggest BE. Other findings, such as hiatal hernia, thickened mucosal folds and gastroesophageal reflux are also frequently seen but not as specific. The finding of focal mural deformities associated with fixed transverse folds and minimal distensibility of the esophagus at
least 4 cm. proximal to the esophagogastric junction also suggests BE [13]. When adenocarcinoma supervenes, its morphology is similar to that of squamous cell carcinoma of the esophagus [14].

Computed tomography

Computed tomography (CT) is most helpful when BE has progressed to adenocarcinoma, wherein CT assists in staging of the cancer and in evaluating direct invasion or distant metastases [13]. The radiologic appearance of esophageal adenocarcinoma on CT is similar to that of squamous cell carcinoma. CT is reliable in detecting local tumor invasion and metastases in the liver or adrenal glands [15, 16].

Radionuclide imaging

Radionuclide imaging takes advantage of the fact that the BE mucosa can secrete acid [17]. Since 1973 the selective concentration of 99mTc-pertechnetate in gastric mucosa has been used to diagnose BE [1, 18, 19]. This technique allows for simple reproducible studies as these patients are followed clinically. Figure 1 shows a scintiscan obtained in a patient with BE. Radionuclide imaging has a high specificity but sensitivity is low, with only eight of 17 patients (47%) giving positive images in one study [1]. Swallowed saliva can give a false positive test and patients are asked to drink a glass of water after initial imaging. This eliminates any saliva. A gradual decline in Tc99m-04 uptake as noted by serial scintigraphy in a a patient with BE may suggest either healing of the BE or transformation of the BE to malignancy.

Figure 1. Radionuclide scintigraphy showing a positive scan for Barrett's esophagus.
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Endoscopic ultrasound

Endoscopic ultrasound (EUS) allows a detailed circumferential image of the esophageal wall. As measured by EUS the esophageal wall is significantly thickened in the columnar-lined portion of BE, so that EUS can be used to follow patients with BE [20]. However, a study designed to test this function of EUS found that the current generation of echo-endoscopes does not reliably differentiate between benign and malignant wall thickening in patients with BE [21].

Primarily because none of these imaging studies provides material for a histologic diagnosis, endoscopy is the current surveillant tool of choice for most gastroenterologists [15, 22, 23]. This practice prevails despite the fact that from one endoscopic examination to another inconsistencies in the ability to detect specialized columnar epithelium are common and complicate the accurate endoscopic diagnosis of BE [24, 25]. Endoscopy also has a higher morbidity and expense than the imaging techniques. It has been suggested that yearly endoscopy is appropriate if length of life is the only criterion, whereas endoscopy every 2-3 years will provide the greatest quality-adjusted life expectancy [26]. A way to provide histologic surveillance without endoscopy is provided by balloon cytology, a technique now being evaluated [27-29].

Conclusion

Clinicians have many ways in which to diagnose and follow the course of BE. The many therapeutic modalities available for the treatment of BE underscore the value of detecting and following these patients. Today's care includes profound acid suppression with proton pump inhibitors, laser ablation of Barrett's epithelium, and photodynamic therapy [22, 30] in addition to surgery. Hopefully, proper surveillance will increase the incidence of cure when carcinoma intervenes, as well as assist in the long-term care of the basic disease process.

References

1. Chaudhuri TK, Fink S, Bird JA. Radionuclide study of esophageal disorders: current clinical status and future directions. Appl Radiol 1988;17:70-77.

2. Probert CSJ, Jayanthi V, Mayberry JF. Barrett's esophagus-a review. Q J Med 1991;81:883-889.

3. Menke-Pluymers MB, Hop WC, Dees J, et al. Risk factors for the development of an adenocarcinoma in columnar-lined (Barrett) esophagus. Cancer 1993;72:1155-1158.

4. Miros M, Kerlin P, Walker N. Only patients with dysplasia progress to adenocarcinoma in Barrett's oesophagus. Gut 1991;32:1441-1446.

5. Spechler SJ, Zeroogian JM, Antonioli DA, et al. Prevalence of metaplasia at the gastro-oesophageal junction. Lancet 1994;344:1533-1536.

6. Reid BH. Barrett's esophagus and esophageal adenocarcinoma. Gastroenterol Clin North Am 1991;20:817-834.

7. Blot WJ, Devesa SS, Kneller RW, et al. Rising incidence of adenocarcinoma of the esophagus and gastric cardia. JAMA 1991;265:1287-1289.

8. Richter JE. Endoscopic surveillance of Barrett's esophagus: another viewpoint. Am J Gastroenterol 1993;88:630-632.

9. Williamson WA, Ellis FH Jr, Gibb SP, et al. Barrett's esophagus: prevalence and incidence of adenocarcinoma. Arch Intern Med 1991;151:2212-2216.

10. Reid BJ, Blount PL, Rabin CE, et al. Flow-cytometric and histologic progression to maligancy in Barrett's esophagus: prospective endoscopic surveillance of a cohort. Gastroenterology 1991;102:1212-1219.

11. Clark GWB, Ireland AP, DeMeester TR. Dysplastic Barrett's: is continued surveillance appropriate? Gastroenterology 1994;106:1128-1133.

12. Chernin MM, Amberg JR, Kogan FJ, et al. Efficacy of radiologic studies in the detection of Barrett's esophagus. Am J Roentgenol 1986:147:257-260.

13. Glick SN. Barium studies in patients with Barrett's esophagus: importance of focal areas of esophageal deformity. Am J Roentgenol 1994;163:65-67.

14. Chen MYM, Frederick MG. Barrett esophagus and adenocarcinoma. Radiol Clin North Am 1994;32:1167-1181.

15. Levine MS, Halvorsen RA. Esophageal carcinoma. In: Gore RM, Levine MS, Lauffer I, eds. Textbook of gastrointestinal radiology. Philadelphia: WB Saunders, 1994:446-478.

16. Halvorsen RA, Jr, Thompson WM. Ct of esophageal neoplasms. Radiol Clin North Am 1989;27:667-685.

17. Mangla JC. Acid and pepsin production by Barrett's epithelium: role of radionuclide imaging in diagnosis. In: Spechler SJ, Goyal RK, eds. Barrett's esophagus. New York: Elsevier Science Publishing Co, 1985.

18. Chaudhuri TK, Chaudhuri TK, Fink S. In radionuclide scans of Barrett's esophagus, what is the involvement of mucoid and parietal cells in pertechnetate excretion? In: Giuli R, ed. OESO. The esophageal mucosa. Paris: Elsevier, 1994:860-863.

19. Yegelwel EJ, Bushnell DL, Fisher SG, et al. Technetium pertechnetate esophageal imaging for detection of Barrett's esophagus. Dig Dis Sci 1989;34:1075-1078.

20. Srivastava AK, Vanagunas A, Kamel P, et al. Endoscopic ultrasound in the evaluation of Barrett's esophagus: a preliminary report. Am J Gastroenterol 1994;89:2192-2195.

21. Falk GW, Catalano MF, Sivak MV Jr, et al. Endosonography in the evaluation of patients with Barrett's esophagus and high-grade dysplasia. Gastrointest Endosc 1994;40:207-212.

22. Falk GW. Barrett's esophagus. Gastrointest Endosc Clin North Am 1994;4:773-789.

23. Levine DS, Haggitt RC, Blount PL et al. An endoscopic biopsy protocol can differentiate high-grade dysplasia from early adenocarcinoma in Barrett's esophagus. Gastroenterology 1992;105:40-50.

24. Kim SL, Waring JP, Spechler SJ, et al. Diagnostic inconsistencies in Barrett's esophagus. Gastroenterology 1994;10;7:945-949.

25. Atkinson M. Barrett's oesophagus-to screen or not to screen? Gut 1989;30:2-5.

26. Provenzale D, Kemp JA, Arora S, et al. A guide for surveillance of patients with Barrett's esophagus. Am J Gastroenterol 1994;89:670-680.

27. Fennerty MB, DiTomasso J, Morales TG, et al. Screening for Barrett's esophagus by balloon cytology. Am J Gastroenterol 1995;90:1230-1232.

28. Brandt LJ, Coman E, Schwartz E, et al. Use of a new cytology balloon for diagnosis of symptomatic esophageal disease and acquired immunodeficiency syndrome. Gastrointest Endosc 1993;39:559-561.

29. Shen O, Liu SF, Dawsey SM, et al. Cytologic screening for esophageal cancer. Results from 1287 subjects from a high risk population in China. Int J Cancer 1993;54:185-188.

30. Deviere J, Buset M, Dumonceau JM, et al. Regression of Barrett's epithelium with omeprazole. N Engl J Med 1989;320:1497-1498.


Publication date: May 1998 OESO©2015