Primary Motility  Disorders of the  Esophagus
 The Esophageal
 Esophagogastric  Junction

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Volume: Barrett's Esophagus
Chapter: Screening and surveillance

Should patients with purely histologic metaplasia be on a surveillance program?

A.J. Cameron (Rochester)

A long segment Barrett's esophagus (LSBE) may be defined as 3 cm or longer of visible columnar epithelium in the esophagus, with intestinal metaplasia (IM) on biopsy. A short segment Barrett's esophagus (SSBE) may be defined as visible columnar epithelium in the esophagus of less than 3 cm length. Both LSBE and SSBE are associated with adenocarcinoma, the risk being more clearly defined and possibly greater for LSBE than for SSBE. If biopsies are taken from patients with a normally located Z-line, and no endoscopically visible Barrett's esophagus of any length, many will be found to have histologic IM of the gastric cardia. The writer will use the proposed classification of intestinal metaplasia of Sharma et al. [1], the 3 categories being LSBE, SSBE, and IM of the gastric cardia. This makes a distinction between the finding of IM in short tongues or segments of columnar mucosa extending into the lower esophagus, and the finding of IM on biopsies taken immediately below a normally located Z-line, which may be a different condition [2]. The following Table I contains information from papers [3-6] in which IM of the gastric cardia was considered separately from cases of SSBE. Biopsies were taken for research purposes in consecutive upper endoscopic examinations on patients examined for clinical indications, including those with and without reflux symptoms. These patients had a normally located Z-line seen at endoscopy. Thus, about 15% of adults having endoscopy have IM of the gastric cardia if biopsies are taken routinely. Although this is not a true population-based sample, there is no reason to believe that the prevalence of IM of the gastric cardia found on consecutive endoscopies is much different from the general population of similar age. It is noted that the prevalence of IM of the gastric cardia increases with age and, unlike LSBE, is similar in males and in females [6]. In 2 US population based studies, the annual incidence of adenocarcinoma of the cardia for males and females combined was 2.1 [7], and in our recent Olmsted County study 2.0/100,000.

Table I.

There are no long term prospective follow-up studies to show the cancer risk in subjects with IM of the gastric cardia. It is possible to get an approximate estimate from combining data already available, as follows. Let us consider an area with a stable population of 100,000 persons of all ages. If the mean age at death is 80 years, 1,250 people in this population die each year from all causes. Assume that 15% of persons (over age 60) have IM of the gastric cardia, although most have never had a biopsy to show this. Therefore, about 15% of the 1,250 persons dying have IM of the gastric cardia, 188 persons. In the population of 100,000, 2 persons per year die from adenocarcinoma of the cardia. Supposing that every adenocarcinoma of the cardia begins in an area of IM of the gastric cardia, then 1 in 94 (2/188) patients with IM of the gastric cardia might develop adenocarcinoma of the cardia in their lifetime. Suppose that a typical patient is found to have IM of the gastric cardia on biopsy at age 55, with a 25-year remaining life expectancy. For each year of expected life, the risk of adenocarcinoma of the cardia is 1 in 94 times 1 in 25, that is a cancer incidence of 1 in 2,350 patient-years for this individual

The risk of adenocarcinoma of the cardia developing in IM of the gastric cardia is likely overestimated above. In 2 series, 42% of adenocarcinomas of the cardia developed in short or long segments of Barrett's esophagus [8, 9]. In some cases, no Barrett's esophagus or IM of the gastric cardia is found in cases of adenocarcinoma of the cardia.

In a decision analysis paper on cancer in Barrett's esophagus, Provenzale et al. [10] concluded that if the cancer incidence was less than 1 in 420 patient-years, the risks of surveillance and esophagectomy would outweigh any benefit in terms of length and quality of life.

It seems clear that the risk of adenocarcinoma of the cardia in patients with IM of the gastric cardia is very low. The writer does not recommend routine surveillance in such patients.


1. Sharma P, Morales TG, Sampliner RE. Short segment Barrett's esophagus-the need for standardization of the definition and of endoscopic criteria. Am J Gastroenterol 1998;93:1033-1036.

2. Nandurkar S, Talley NJ. Barrett's esophagus: the long and the short of it. Am J Gastroenterol 1999;94:30-40.

3. Spechler SJ, Zeroogian JM, Wang HH, Antonioli DA, Goyal RK. The frequency of specialized intestinal metaplasia at the squamo-columnar junction varies with the extent of columnar epithelium lining the esophagus. Gastroenterology 1995;108:A224.

4. Cameron AJ, Kamath PS, Carpenter HA. Prevalence of Barrett's esophagus and intestinal metaplasia at the esophagogastric junction. Gastroenterology 1997;112:A 82.

5. Trudgill NJ, Suvarna SK, Kapur KC, Riley SA. Intestinal metaplasia at the squamocolumnar junction in patients attending for diagnostic gastroscopy. Gut 1997;41:585-589.

6. 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. The Central Finland Endoscopy Study Group. Am J Gastroenterol 1999;94:913-918.

7. Devesa SS, Blot WJ, Fraumeni JF. Changing patterns in the incidence of esophageal and gastric carcinoma in the United States. Cancer 1998;83:2049-2053.

8. Clark GWB, Smyrk TC, Budiles P, Hoeft SF, Peters JH, Kiyabu M, Hinder RA, Bremner CG, DeMeester TR. Is Barrett's metaplasia the source of adenocarcinomas of the cardia? Arch Surg 1994;129:609-614.

9. Cameron AJ, Lomboy CT, Pera M, Carpenter HA. Adenocarcinoma of the esophagogastric junction and Barrett's esophagus. Gastroenterology 1995:109:1541-1546.

10. Provenzale D, Schmitt C, Wong JB. Barrett's esophagus: a new look at surveillance based on emerging estimates of cancer risk. Am J Gastroenterol 1999;94:2043-2053.

Publication date: August 2003 OESO©2015