Prevalence of intestinal metaplasia according to the length of the specialized columnar epithelium lining the distal esophagus in patients with gastroesophageal reflux

Abstract

The diagnosis of Barrett's esophagus is based on the presence of intestinal metaplasia (IM) at the distal esophagus. The aim of this study was to determine the prevalence of IM in patients with symptoms of gastroesophageal reflux in whom endoscopically a segment of distal esophagus was covered by columnar epithelium (CE). In a prospective, descriptive and transversal study, 492 patients (33%) from 1480 patients with gastroesophageal reflux, in whom endoscopic evaluation demonstrated the presence of a short-segment CE measuring less than 3 cm or a long-segment CE measuring more than 3 cm, were evaluated. From each patient, several biopsy specimens were taken, which were stained with hematoxylin-eosin and Alcian blue pH 2.5. Out of 492 cases, 421 patients (86%) presented with a short-segment CE and 71 patients (14%) had a long-segment CE. Among these 71 cases, 38 had a 3-6 cm-length CE, 21 patients had a 6.1-10 cm-length CE and 12 patients had CE more than 10.1 cm in length. Endoscopic short-segment CE was six times more frequent than long-segment CE. The prevalence of IM was 35% among patients with short-segment CE and increased progressively according to the length of CE, being 100% in patients with > 10 cm in length. Therefore, true short-segment BE was three times more frequent during endoscopic studies than long-segment BE. Dysplasia in the metaplastic epithelium also increased parallel to the length of the CE. True BE (presence of IM at the columnar epithelium lining the distal esophagus), was present in 13.6% of all patients with symptoms of gastroesophageal reflux submitted to endoscopic evaluation. Short-segment BE is three times more frequent than long-segment BE, and endoscopic and bioptic evaluation is fundamental in all cases with gastroesophageal reflux who exhibit some segment of the distal esophagus lined by columnar epithelium, even if it is > or = 1 cm long.

Videoendoscopy and histopathology of the esophagogastric junction in patients with gastroesophageal reflux disease

“…In agreement with our observation, Chandrasoma et al [1,[6][7][8] and Lenglinger et al [21] recently found presence of IM within cardiac mucosa but absence of IM within oxyntocardiac mucosa. These data and other recent observations of cardiac mucosa indicate that IM is frequently found within CLE and that its presence or absence may define those patients at risk for development of IM and progress towards adenocarcinoma of the esophagus, irrespective of presence [12,13,21,28,45] or absence [44,46,47] of symptoms associated with GERD. Future studies should address the relevance of CLE in design of treatments for such patients [48][49][50][51][52].…”

“…Nevertheless, we feel that the findings of the present and other recent studies [2,21,28] justify evaluation of the multilevel biopsy protocol for risk assessment for development of esophageal adenocarcinoma in patients with GERD within the academic setting (i.e. prospective clinical studies).…”

“…Presence of IM within endoscopic short-segment CLE (≤ 3cm) has been variously reported to be 13% [42], 30.5% [12] and 35% [28]. Johansson et al [43] recently reported the incidence of IM in the absence and presence of endoscopically visible CLE as 12% and 36%, respectively.…”

“…Following inspection of the duodenum and stomach, including four antegrade biopsies from gastric antrum and corpus, respectively, the esophagogastric junction was examined using retroflexed and antegrade vision [3,21,28]. None of the patients showed endoscopic evidence of duodenal, gastric or esophageal ulcer or tumor [29][30][31][32][33].…”

Prevalence of Barrett's esophagus in individuals without typical symptoms of gastroesophageal reflux disease

“…These divergences have been discussed in the literature, with emphasis on these types of metaplasia in the oncogenesis of adenocarcinomas of the esophagogastric junction (10,25,34) . The large number of studies published over the last years investigating the relationship between GERD, esophagitis, H. pylori, carditis, Barrett's esophagus and the presence of junctional intestinal metaplasia had only a single implicit or explicit objective, i.e., to obtain information that would permit to reduce the increasing incidence of adenocarcinomas of the esophagogastric junction observed over the last two decades (24) .…”