Primary Motility  Disorders of the  Esophagus
 The Esophageal
 Esophagogastric  Junction

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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?



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Publication date: August 2003 OESO©2015