Primary Motility  Disorders of the  Esophagus
 The Esophageal
 Mucosa
 The
 Esophagogastric  Junction
 Barrett's
 Esophagus

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OESO©2015
 
Volume: Barrett's Esophagus
Chapter: Diagnosis
 

Is intestinal metaplasia at the gastric cardia more often found in Barrett patients than in those without Barrett's esophagus?

Y.-T. Bak (Seoul)

Theoretically this question could be easily answered if there were enough pertinent data on this topic from autopsy or surgical specimen. This is not the case yet. In an attempt to give an answer based on non invasive and widely available investigative methods, that is, endoscopy, the following questions should be answered first: what is the precise location of the gastroesophageal junction (GEJ) and how can it be identified correctly by endoscopy? What is Barrett's esophagus and how can it be diagnosed accurately by endoscopy?

The latter question now has become clearer, thanks to the recent efforts of many investigators, although there are still several areas of controversy. The former one is still not so easy to be answered during endoscopy, although a generally accepted marker of GEJ is the proximal end of the longitudinal gastric mucosal folds [1].

A recent definition of Barrett's esophagus is the presence of specialized columnar epithelium on the esophageal mucosa regardless of the length of columnar-lined esophagus (CLE) [2]. However, such a definition may lead to a false positive diagnosis of Barrett's esophagus in case of an eccentric Z-line or transient minor proximal migration of Z-line which can be observed from time to time during endoscopy. Including intestinal metaplasia (IM) of "gastric cardia" into Barrett's "esophagus" does not seem to make sense.

We investigated the prevalence of specialized columnar epithelium on the lower esophagus and gastric cardia in Korea [3] where gastric IM is known to be quite prevalent [4]. Data from 77 consecutive cases with short segment CLE (SSCLE) (M:F 64:13, mean age 44.4 years) and from 28 cases without endoscopically visible CLE (M:F 16:12, mean age 53.4 years) were compared. The rate of specialized columnar epithelium detected at the gastric cardia in those cases without any endoscopic CLE (57.1%) was significantly higher than that of specialized columnar epithelium in those with endoscopic SSCLE (31.2%).

Although endoscopic examination can usually distinguish columnar epithelium from squamous epithelium on the esophagus without staining with Lugol solution, the type of columnar epithelium cannot be diagnosed on endoscopic appearance alone. Distinction between specialized columnar epithelium and gastric type columnar epithelium can be made only by histology. Gastric type columnar epithelium may normally line a short segment of the distal esophagus, circumferentially or eccentrically [1].

We found that as much as 57.1% of Koreans without visible CLE, that is, without Barrett's esophagus, undergoing routine upper gastrointestinal endoscopy had specialized columnar epithelium at the cardia level [3]. Our detection rate of specialized columnar epithelium at the cardia was much higher than that of reports from other countries (0-18%) [5-8]. All these studies as ours, did not use methylene blue-directed biopsy and the difference observed might be due to the difference in the prevalence of gastric IM in various countries. Our detection rate of cardiac specialized columnar epithelium was very similar to the reported prevalence (56.6%) of gastric IM in Korean adults [4].

Recently, vital staining with methylene blue during endoscopy has been used for a more accurate detection of specialized columnar epithelium of gastric cardia and CLE [9-11]. Methylene blue-directed target biopsy led to the identification of a much bigger proportion of specialized columnar epithelium in endoscopic biopsy samples compared with those obtained by random biopsy. This was particularly evident in patients with short segment Barrett's esophagus (SSBE) (94% by target biopsy versus 54% by random biopsy) [11]. The detection rate of IM at the gastric cardia in our cases both with and without Barrett's esophagus, might have been higher, if we had employed this technique. A recent paper from Germany using this technique reported a very high prevalence of specialized columnar epithelium at the level of normal looking cardias without any endoscopic CLE (72.7%) [12]. This study suggested that specialized columnar epithelium might be a quite prevalent condition in those people undergoing endoscopy whether they have endoscopically visible CLE or not, and whether they are in countries where prevalence of gastric IM possibly associated with H. pylori infection, is known to be low or high. If IM at the gastric cardia has a quite important prevalence, the goblet cell metaplasia of the "gastric" mucosa cannot be differentiated from the true SSBE by ordinary histological examination.

Endoscopic estimation of the length of CLE may vary from time to time [13]. To try to minimize this potential confusion, we excluded cases with CLE of less than 0.5 cm in length. However, it cannot be stated that the cases with SSBE and those without any Barrett's esophagus were perfectly differentiated. It may be technically very difficult (or practically impossible) to differentiate the "ultra-short" segment Barrett's esophagus from the cardia with IM even by ordinary microscopy as well as by endoscopy. These days, efforts to differentiate the two conditions using cytokeratin staining allow to foresee a promising achievement [14].

However, both conditions may not be significantly different as potentially premalignant conditions of adenocarcinoma at the GEJ [15], although the conceptual underlying pathogenetic mechanisms between the two conditions, that is, GERD or H. pylori are quite different [16]. Therefore, both conditions may more interestingly be grouped together under a title of "specialized columnar epithelium around GEJ" rather than separated into two different entities.

Barrett's esophagus has been known to be associated with severe GERD [17] and a high risk of malignant transformation, requiring strict treatment for reflux and surveillance program for early detection of cancer [18]. However, many patients with specialized columnar epithelium around GEJ have little evidence of GERD, and, in such cases, the exact risk of malignancy is not yet clear [2]. Therefore, a new program for surveillance and detection of cancers, and interventional strategy to treat these lesions and prevent malignant transformation needs to be developed.

Is IM at the gastric cardia more often found in Barrett patients than in those without Barrett's esophagus?

No.

References

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2. Spechler SJ, Goyal RK. The columnar-lined esophagus, intestinal metaplasia, and Norman Barrett. Gastroenterology 1996;110:614-621.

3. Bak YT, Jung GM, Yeon JE, Kim JS, Byun KS, Kim JH, Kim JG, Lee CH, Kim HK, Won NH. Validity of the specialized columnar epithelium as a diagnostic criterion of the short segment Barrett's esophagus. Korean J Intern Med 1998;13:99-103.

4. Yoon CM, Rew JS, Park KS, Bom HS, Park IC, Yang DH, Cho JK. Subtypes of intestinal metaplasia in endoscopic biopsies of various gastric diseases. Kor J Gastroenterol 1987;19:13-17.

5. Spechler SJ, Zeroogian JM, Antonioli DA, Wang HH, Goyal RK. Prevalence of metaplasia at the gastro-esophageal junction. Lancet 1994;344:1533-536.

6. Weston AP, Krmpotich PT, Cherian R, Dixon A, Topalovski M. Prospective evaluation of intestinal metaplasia and dysplasia within the cardia of patients with Barrett's esophagus. Dig Dis Sci 1997;42:597-602.

7. Voutilainen M, Farkkila M, Juhola M, Nuorva K, Mauranen K, Mantynen T, Kunnamo I, Mecklin JP, Sipponen P. Specialized columnar epithelium of the esophagogastric junction: prevalence and associations. Am J Gastroenterol 1999;94:913-918.

8. Polkowski W, van Lanschot JJ, ten Karte FJ, Rolf TM, Polak M, Tytgat GN, Obertop H, Offerhaus GJ. Intestinal and pancreatic metaplasia at the esophagogastric junction in patients without Barrett's esophagus. Am J Gastroenterol 2000;95:617-625.

9. Canto MI, Setrakian S, Petras RE, Blades E, Chak A, Sivak MV Jr. Methylene blue selectively stains intestinal metaplasia in Barrett's esophagus. Gastrointest Endosc 1996;44:1-7.

10. Morales TG, Bhattacharyya A, Camargo E, Johnson C, Sampliner RE. Methylene blue staining for intestinal metaplasia of the gastric cardia with follow-up for dysplasia. Gastrointest Endosc 1998;48:26-31.

11. Canto MI, Setrakian S, Willis J, Chak A, Petras R, Powe NR, Sivak MV Jr. Methylene blue-directed biopsies improve detection of intestinal metaplasia and dysplasia in Barrett's esophagus. Gastrointest Endosc 2000;51:560-568.

12. Kiesslich R, Herrmann G, Jung M. Methylene blue as a screening method for Barrett's esophagus. Endoscopy 1999;31:E58.

13. Kim SL, Waring JP, Spechler SJ, Sampliner RE, Doos WG, Krol WF, Williford WO, The Department of Veterans Affairs Gastroesophageal Reflux Study Group. Diagnostic inconsistencies in Barrett's esophagus. Gastroenterology 1994;107:945-949.

14. Ormsby AH, Goldblum JR, Rice TW, Richter JE, Falk GW, Vaezi MF, Gramlich TL. Cytokeratin subsets can reliably distinguish Barrett's esophagus from intestinal metaplasia of the stomach. Hum Pathol 1999;30:288-294.

15. Kalish RJ, Clancy PE, Orringer MB, Appelman HD. Clinical, epidemiologic, and morphologic comparison between adenocarcinomas arising in Barrett's esophageal mucosa and in the cardia. Gastroenterology 1984;86:461-467.

16. Goldblum JR, Vicari JJ, Falk GW, Rice TW, Peek RM, Easley K, Richter JE. Inflammation and intestinal metaplasia of the gastric cardia: the role of gastroesophageal reflux and H. pylori infection. Gastroenterology 1998;114:633-639.

17. Dias Pereira A, Suspiro A, Chaves P, Saraiva A, Gloria L, Mendes de Almeida JC, Leitao CN, Soares J, Mira FC. Short segments of Barrett's epithelium and intestinal metaplasia in normal appearing oesophagogastric junctions: the same or two different entities? Gut 1998;42:659-662.

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


Publication date: August 2003 OESO©2015