Primary Motility  Disorders of the  Esophagus
 The Esophageal
 Esophagogastric  Junction

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Volume: Barrett's Esophagus
Chapter: Diagnosis

What is the correlation between foveolar hyperplasia in the cardia and Barrett's esophagus?

H.D. Appelman (Ann Arbor)

Several histologic studies have found that a variety of changes occur often in the gastric cardia, including inflammation and goblet cells. In some of these studies, both inflammation and goblet cells have been blamed on gastroesophageal reflux. Since Barrett's mucosa is a post reflux columnar metaplasia, it would seem likely that some of the refluxers in these studies would have had Barrett's mucosa. In fact, however, specific changes in the cardia in Barrett's patients have hardly been addressed at all. The reasons for this probably relate to the problem in identifying the gastroesophageal junction (GEJ) in Barrett's esophagus. In people without Barrett's mucosa, the squamocolumnar junction is the line, often irregular, between esophageal squamous epithelium and proximal gastric columnar epithelium that is usually cardiac type. In Barrett' esophagus, the squamocolumnar junction is a new line that lies in the esophagus between the residual squamous epithelium and the new, metaplastic Barrett's columnar epithelium. In order to identify the GEJ in these patients, the endoscopist has to rely on finding the top of the most proximal gastric fold as the marker of the most proximal point in the stomach. Theoretically, biopsies from that exact point should contain the junction between the Barrett's and the cardiac mucosae, and allow for studies of the cardia in Barrett's patients. Apparently though, this is not such an easy landmark to identify, especially in patients with hiatal hernias (HH), and almost all Barrett's patients have HH [1]. Furthermore, it is very common for biopsies from within a Barrett's segment to contain columnar mucosa that has no goblet cells, and which, therefore, is identical to cardiac mucosa. We do not know if such biopsies are actually part of the Barrett's mucosa or if they are really cardiac mucosa. It has been my experience based upon uncontrolled observations that in Barrett's patients, those biopsies of mucosa that look like gastric cardia are inflamed, but prominent pit hyperplasia is unusual. The inflammation is almost ubiquitous in cardiac mucosae, regardless of the presence of Barrett's mucosa more proximally. Almost everyone has some type of chronic carditis.

We also know that in some refluxers, the most proximal gastric fold becomes enlarged and even polypoid. Biopsies of such large polyp-fold complexes invariably have expanded, commonly distorted, even cystic foveolae. In fact the histologic features of these polypoid folds resemble those found in the gastric type hyperplastic polyps [2]. We suspect that some refluxers with such large polypoid proximal folds containing hyperplastic pits must have Barrett's mucosa, but we do not know that for a fact.

In summary, the question to be answered by this discussion is: what is the correlation between foveolar hyperplasia in the cardia and Barrett's esophagus? The answer, based upon remarkably little published data, is that we don't know. Furthermore, we don't even know if it is worth studying.


1. Spechler SJ. The role of gastric carditis in metaplasia and neoplasia at the gastroesophageal junction. Gastroenterology 1999;117:218-228.

2. Lewin KJ, Appelman HD. Tumors of the esophagus and stomach. Fascicle 18, Third Series, Atlas of Tumor Pathology. Washington DC: Armed Forces Institute of Pathology, 1996:211-212.

Publication date: August 2003 OESO©2015