食管高位胃黏膜异位与Barrett食管的对比研究

目的 探讨食管高位胃黏膜异位（HGM）与Barrett食管（BE）患者在症状、内镜下表现、组织病理学、Hp感染以及细胞角蛋白染色方面的差异。方法选择对2004年2月-2005年9月明确诊断的BE患者152例（BE组）、食管高位HGM患者52例（食管高位HGM组）,收集两组患者临床资料,总结各组患者的症状特点、各型黏膜的常规内镜下和放大内镜下特点;比较各型黏膜的组织病理学结果,快速尿酶法及Warthin—Starry银染检测病灶部位及胃窦部Hp感染情况,免疫组化法检测细胞角蛋白CK7、CK20、CK13及CK19的表达情况。结果BE组有反流症状者占64．5％（98／152）,显著高于食管高位HGM组的（13．5％,7／52）（X^2=40．36,P〈0．01）。放大内镜下BE黏膜小凹表现为点状46例、条纹状65例、绒毛状41例,而食管异位胃黏膜的小凹全表现为条纹状。组织病理学分型上,152例BE患者中属胃底型56例、交界型39例、特殊肠化型57例;而52例食管高位HGM患者中31例为胃底型、16例为交界型、5例为胃窦腺型,无一例发现有杯状细胞。BE黏膜中中、重度炎症细胞浸润所占比例为63．2％（96／152）,显著高于食管异位胃黏膜的28．8％（15／52）（P〈0．01）;而两组胃窦部中、重度炎症细胞浸润所占比例分别为44．7％（68／152）、51．9％（27／52）,差异无统计学意义（P〉0．05）。BE黏膜Hp检出率为32．2％（49／152）,BE组胃窦部黏膜Hp检出率为48．0％（73／152）;食管异位胃黏膜Hp检出率为44．2％（23／52）,食管高位HGM组胃窦部黏膜Hp检出率为40．4％（21／52）;两组Hp感染检出率差异均无统计学意义（P〉0．05）。细胞角蛋白免疫组化检测中,食管异位胃黏膜以及正常的食管鳞状上皮中无CK7的阳性表达,而BE黏膜的3种类型的上皮中均有表达;CK20和CK19在BE黏膜和食管异位胃黏膜中均有阳性表达;CK13     

共聚焦显微内镜下Barrett食管上皮的分布特点

目的 探讨共聚焦显微内镜下Barrett食管(BE)上皮类型的分布特点.方法 选取胃镜检查疑诊为BE的112例患者纳入研究,对食管下段柱状上皮进行共聚焦内镜检查,实时预测BE上皮类型、判断肠上皮化生的累及范围,随后对所检查部位黏膜行活组织病理检查,分析普通内镜和共聚焦显微内镜表现与病理组织学诊断结果的关系.结果 共计94例患者被确诊为BE,普通内镜下以岛型最为常见(54.3％),短段BE比例显著高于长段BE(86.2％比13.8％),共聚焦显微内镜下可分辨特殊肠上皮化生、贲门腺和胃底腺上皮,其准确度分别为94.7％、89.4％和91.5％.靶向活组织病理检查发现长段BE中的肠上皮化生比例(9/13)高于短段BE(33.3％,x2=4.684,P=0.039),环周型和舌型BE的肠上皮化生比例(11/17和65.4％)均显著高于岛型(15.7％,x2值分别=15.217和19.399,P值均＜0.01).短段BE与长段BE间,岛型、环周型和舌型BE间的肠上皮化生范围均无明显差异.结论 共聚焦显微内镜可准确分辨BE上皮的组织类型,镜下形态以岛型多见,但环周型和舌型的肠上皮化生比例更高,长段BE中的肠上皮化生比例高于短段BE.     

Barrett食管的临床病理特征分析

目的探讨内镜下拟诊为Barrett食管(BE)患者的临床症状、内镜下表现类型和病理特征之间的关系。方法对184例内镜下拟诊为BE的患者进行临床症状评估,HE染色行病理组织学分析。并对临床症状、内镜下表现类型及病理特征之间的关系进行相关分析。结果内镜下拟诊184例BE患者,反酸33例次,反食7例次,烧心23例次,胸骨后疼痛13例次,上腹痛70例次,上腹胀38例次,其中10例患者有食管外症状(咳嗽、咽炎等);37例无明显症状。内镜表现类型岛型128例,环周型43例,舌型13例。活检证实有柱状上皮化生88例(占47.8%),其中有46例可见肠上皮化生,发现1例不典型增生。病理确诊的46例肠化BE和42例非肠化BE患者的反酸发生率明显高于非BE患者,其他临床症状比较无明显差异;内镜下拟诊的3种类型的BE患者临床主要症状比较无明显差异;内镜表现为环周型、岛型和舌型BE的柱状上皮化生和肠化生的检出率无明显差异。结论(1)病理确诊的BE患者反酸的发生率明显高于非BE患者。(2)BE患者内镜表现类型与症状无关。(3)内镜表现以岛状多见,柱状上皮化生和肠上皮化生在3型BE中检出率无差异。     

Barrett食管临床与内镜探讨（附316例分析）

目的探讨Barrett食管(BE)的临床及内镜特点。方法回顾性分析我院自1994-02／2003-10间316例BE的临床及内镜资料，探讨其相关特点。结果BE内镜检出率1．75％(316／18037例)。316例BE中，男性多于女性，多见于中老年人(266例)，临床表现胃食管返流症状占81．4％(257／316例)，Hp阳性率为69．6％。BE内镜表现为食管下段鳞状上皮中出现红色柱状上皮区，内镜分型以全周型51．9％(164／316例)最多，岛型33．2％(105／316例)次之，舌型14．9％(47／316例)最少；短节段BE(218例)多于长节段BE(98例)；多伴随不同程度的返流性食管炎(167例)。结论BE临床表现无特异性。应进行内镜盐测，以提高BE癌变检出率。     

氩离子凝固术治疗Barrett食管36例

Barrett食管（BE）是指内镜下发现并被病理组织学证实在胃食管连接处（GEJ）以上出现的鳞状上皮被伴肠化生（即含杯状细胞）的柱状上皮所替代的现象。BE是胃食管反流病的常见并发症之一．欧美报告反流性食管炎中BE检出率为10％～15％，国内报道BE的检出率为2．21％。BE治疗的目的在于消除和逆转BE的肠化，     

Barrett食管13例临床分析

目的 探讨Barrett食管（BE）的内镜表现、病理特征以及与食管腺癌的关系。方法 分析13例BE患者的临床表现、内镜诊断及病理特点。结果所有患者均有反酸、烧心感等症状，其中同时伴食管裂孔疝者3例，内镜下全周型2例、岛型7例和舌型4例。活组织病理检查均有柱状上皮化生。其中不典型增生1例，随访2年后发现癌变。结论 BE是反流性食管炎发展的一种结果，可导致食管腺癌，其诊断需内镜和活组织检查，药物治疗只能改善症状，应定期进行随访，发现恶变及早手术。     

中国人Barrett食管临床特点分析

目的 研究中国人Barrett食管（Barrett’s esophagus，BE）的临床特点。方法以“Barrett食管”为检索词，电脑检索1989年～2007年国内公开发表的中文文献，以“Barrett esophagus”和“China”为检索词，电脑在MEDLINE上检索1989年-2007年公开发表有关中国Barrett食管临床研究英文文献，统一纳入标准和排除标准，所得资料进行荟萃分析。结果共41项研究中的4132例BE患者进入本研究：①BE的内镜检出率为2．39％，男女比为2．08：1，平均发病年龄为53．27岁，有典型胃食管反流病（GERD）症状的51．00％；②内镜下形状以岛状居多，为56．81％；特殊肠化生型为36．58％；舌型BE的特殊肠化生检出率较全周型、岛状均显著增高（均P〈0．001）；长段Barrett食管的特殊肠化生型检出率高于短段Barrett食管（P〈0．001）；③492例BE患者平均2年随访，癌变发生率为0．61％。结论我国人内镜BE检出率低于西方人，平均发病年龄低于西方国家报道，癌变发生率与国外报道接近，男性多发、临床症状、特殊肠化生型检出率等与国外报道一致。     

Barrett食管黏膜微细形态改变和CDX2蛋白的表达

目的 研究食管黏膜微细形态的改变和CDX2蛋白表达在Barrett食管（BE）诊断中的意义。方法 采用高清晰内镜观察BE及非BE的胃食管反流疾病（GERD）患者的齿状线附近黏膜的小凹及微细血管形态变化，并采用免疫组化方法检测CDX2蛋白的表达。结果 48例BE中，40例可观察到食管下段的栅状血管末端有不同程度的下移现象，而60例非BE的GERD患者均未发现有血管下移现象；放大内镜下BE黏膜可分为绒毛型、条纹型和小点型，绒毛型肠上皮化生（肠化）检出率显著高于条纹型及点状（P〈0.01）；CDX2蛋白不但在肠化的杯状细胞表达，而且在BE和非BE的柱状上皮中亦有表达，绒毛状上皮CDX2表达的阳性率显著高于条纹状（P〈0.01）和点状上皮（P〈0．05）。结论 观察食管黏膜微细形态有助于对BE的诊断、分型及了解其相关病理背景，CDX2蛋白是一种具有较高敏感性的肠上皮特异标志物，有助于判断早期肠化的发生，对BE的早期诊断可能有重要价值。     

内镜下氩离子凝固术治疗Barrett食管的临床研究

目的探讨内镜下氩离子凝固术（APC）联合抑酸治疗对Barrett食管的临床疗效。方法对32例病理证实伴有肠上皮化生的Barrett食管，在内镜下以APC完全毁损化生黏膜，并予以口服奥美拉唑40mg／d抑酸治疗。从末次治疗开始进行为期12个月的内镜随访监测，每次内镜检查时对再生的鳞状上皮进行间隔1cm的四象限活检，对可疑病灶进行针对性的活检。结果32例患者共接受61次APC治疗，31例（96．9％）达到完全的鳞状上皮再生，1例（3．1％）在再生的鳞状上皮间混有岛状的柱状上皮；除1例出现食管轻度狭窄外，无其他并发症的出现。12个月后，共有4例出现内镜下可见的复发，另活检发现d例内镜下无异常患者的再生鳞状上皮下有柱状上皮残留。结论BE的内镜下APC联合抑酸治疗安全有效，能使鳞状上皮替代BE黏膜，但仍有一定比例的复发和残留。     

FICE辅助下氩等离子凝固术治疗肠化型Barrett食管的效果观察

目的：观察FICE辅助下氩等离子凝固术（ APC）治疗肠化型Barrett食管（ BE）的效果。方法选择肠化型BE患者72例，随机分为FICE辅助下APC治疗组38例（观察组）、普通胃镜下APC治疗组34例（对照组），分别在FICE内镜辅助、普通胃镜下行APC治疗。分别于BE黏膜完全消除后3、6、12个月进行内镜及病理随访。结果观察组首次治疗后内镜治愈率明显高于对照组（ P＜0．05）。观察组显效15例、有效21例、无效2例，总有效率为94．7％，对照组分别为11、19、4、88．2％。两组总有效率比较P＞0．05。结论 FICE辅助下APC治疗肠化型BE虽不能提高治疗效果，但能提高首次治疗后内镜治愈率。     

Detection of Barrett's esophagus after endoscopic healing of erosive esophagitis

BACKGROUND: The presence of erosive esophagitis (EE) in patients presenting for upper endoscopy may prevent the detection of underlying Barrett's esophagus (BE) in the distal esophagus. AIM: To prospectively determine the proportion of patients detected with BE upon repeat endoscopy after healing of EE. METHODS: Patients with endoscopically confirmed EE without BE were treated with standard doses of acid suppression therapy and a repeat endoscopy was performed to assess the presence of BE. If columnar mucosa was visualized in the distal esophagus, targeted biopsies were obtained and all biopsies were evaluated for the presence of intestinal metaplasia. BE was defined as columnar mucosa in the distal esophagus with intestinal metaplasia on biopsy. RESULTS: A total of 172 patients with reflux symptoms were diagnosed with EE without BE on initial endoscopy. They were treated with standard doses of proton pump inhibitor therapy, and after a mean duration of 11 wk (range 8-16 wk), a repeat endoscopy was performed to confirm healing of EE and to document the presence of BE. On repeat endoscopy, EE was completely healed in 116 patients (67%), and of those, BE was suspected in 32 patients (i.e., columnar-lined distal esophagus) and was confirmed in 16 patients (13.8%). In the 56 patients with persistent EE on repeat endoscopy, columnar mucosa in areas of previously healed esophagitis was visualized in 8 and confirmed in 5 patients (8.9% of nonhealed cases). Overall, 21 (12%) patients were confirmed with BE on repeat endoscopy; all men, mean age 61 yr with a median BE length of 0.5 cm (range 0.5-5 cm, interquartile range 0.5 cm). The majority of these patients (N = 19) had short segment Barrett's esophagus (SSBE) (i.e., length <3 cm). CONCLUSIONS: In patients with EE undergoing treatment with acid suppressive therapy, BE (mainly SSBE) is detected in approximately 12% of patients on repeat endoscopy. Patients with reflux symptoms undergoing endoscopy for the detection of BE (i.e., screening) should be treated with acid suppressive therapy prior to endoscopy to enhance the yield of BE. Alternatively, if the goal is to document BE and if EE is found at the initial endoscopy, then repeat endoscopy may be considered after acid suppressive therapy.     

短节段Barrett食管临床研究

目的探讨短节段Barrett食管(SSBE)的临床特征、诊治、随访及其可能发病机制。方法回顾分析52例经内镜和病理确诊的SSBE，重点为内镜特征、病理学改变、食管动力检查结果、内镜复查及疗效观察。结果SSBE内镜下以岛型最多见占86．5％，常规病理证实的特异型肠上皮化生占15．4％，11例患者行24h食管pH和胆汁联合监测及食管测压，72．7％存在异常。21例患者行氩离子凝固术等内镜介入治疗，短期内复查15例SSBE消退。49例复查胃镜者未发现食管癌变。结论SSBE发生与胃酸和胆汁反流相关，内镜下以岛型常见，其肠化生、不典型增生的发生率可能相对较低。     

Does this patient have Barrett's esophagus? The utility of predicting Barrett's esophagus at the index endoscopy

OBJECTIVES: Few studies have evaluated the ability of the endoscopist to predict the presence of Barrett's esophagus (BE) at index endoscopy. The goals of this study were to determine the operating characteristics of endoscopy in diagnosing BE, and to determine the clinical and endoscopic predictors of BE in suspected BE patients at the index endoscopy. METHODS: From September 1993 to October 1997, endoscopic reports were examined to identify patients with suspected BE. All esophageal pathology reports during the same period were evaluated for the presence of specialized intestinal metaplasia. RESULTS: During the study period, 4053 endoscopies were performed on 2393 patients. Eight percent of all procedures were performed for suspected or confirmed BE. Fifty-three patients were known to have BE and thus their reports were excluded from this analysis. Five hundred seventy of the remaining patients had esophageal biopsies performed, and were included in this analysis. Among these 570 patients, 146 were suspected to have BE on endoscopy, while 424 were not suspected to have BE at the time of endoscopy. There were no differences among the two groups in terms of gender, race, and dyspepsia as an indication for the endoscopy. However, suspected BE patients were slightly younger and were more likely to have heartburn, but were less likely to have dysphagia as an indication for the endoscopy. The sensitivity and specificity of the endoscopists' assessments were 82% (95% confidence interval [CI], 72-92) and 81% (95% CI, 78-84), respectively. The positive predictive value and the negative predictive value were 34% and 97%, respectively. The positive likelihood ratio was 4.32 (95% CI, 3.49-5.31) and the negative likelihood ratio was 0.22 (95% CI, 0.13-0.38). Univariate analysis showed that endoscopists diagnosed BE in those with long-segment BE (LSBE) more accurately than in those with short-segment BE (SSBE) (55% vs 25% p = 0.001; odds ratio [OR] = 3.63, 95% CI, 1.71-7.70). Barrett's esophagus was correctly diagnosed in 38.5% of white patients but in only 14.7% of black patients (p = 0.01; OR = 3.63, 95% CI, 1.31-10.13). Multivariable logistic regression identified only the length of the columnar-appearing segment (p = 0.002; OR = 3.33, 95% CI, 1.54-7.17) and race (p = 0.08; OR = 2.31, 95% CI, 0.88-6.03) to be associated with the presence of BE on biopsy. CONCLUSIONS: Barrett's esophagus is frequently suspected at endoscopy; SSBE was more frequently suspected than LSBE, but was correctly diagnosed only 25% of the time, versus 55% for LSBE. Endoscopists diagnosed BE with a sensitivity of 82% and a specificity of 81%. However, the positive predictive value was only 34%, whereas the negative predictive value was 97%. The length of the columnar-appearing segment is the strongest predictor of BE at endoscopy. Alternative methods are needed to better identify BE patients endoscopically, especially those with SSBE.     

福建地区Barrett食管的发病情况和内镜及临床特点

目的研究福建地区Barrett食管(BE)的发病情况和内镜、临床特点及其与反流性食管炎(RE)的关系。方法根据新标准诊断BE,研究BE患者的内镜下检出率、内镜表现、分型及病理检查结果,分析患者的年龄、性别、症状、幽门螺杆菌(Hp)感染情况及其与RE的关系。结果检出BE为总胃镜检查人数的7.90%,男女之比为1.98,平均年龄(45.1±14.8)岁,仅19.15%有典型反流症状。BE中短节段占81.20%,多为舌状、岛状或包含这2种形状的混合型。食管活检组织病理诊断为肠化型占BE的34.83%,9.88%伴异型增生,胃窦Hp阳性率为39.94%。RE检出率为2.07%,比BE显著降低(P<0.01)。8.42%的BE伴RE,32.11%的RE伴BE。结论福建地区BE患病率较高,多为短节段舌状或岛状,约1/3为肠化型,以中年男性多见,常无症状,与RE无明显相关性,部分伴异型增生。BE的临床意义和预后有待于进一步研究。     

Accuracy of magnifying endoscopy with methylene blue in the diagnosis of specialized intestinal metaplasia and short-segment Barrett's esophagus in Japanese patients without Helicobacter pylori infection

BACKGROUND: The use of methylene blue chromoendoscopy in the diagnosis of specialized intestinal metaplasia in short-segment Barrett's esophagus is controversial. This study evaluated the use of magnifying endoscopy with methylene blue for this purpose. METHODS: A total of 30 patients (21 men, 9 women; median age 61 years, range 32-79 years) with short lengths of columnar-lined esophagus were enrolled in a prospective trial of magnifying endoscopy with methylene blue in which the appearance after methylene blue staining was used to target biopsy specimens. Patients were screened for Helicobacter pylori infection, and only those without infection were enrolled (because many Japanese patients have pan-gastritis caused by H pylori infection, and intestinal metaplasia distal to the squamocolumnar junction may be secondary to H pylori-induced gastritis). All biopsy specimens were stained with H and E; MUC2 immunostaining was used to identify specialized intestinal metaplasia. RESULTS: Thirty patients with short-segment columnar-lined esophagus underwent magnifying endoscopy with methylene blue. Ninety-three biopsy specimens were obtained, 33 from methylene blue-stained areas and 60 from unstained areas, each about 7 mm from the marginal edge of stained areas. Specialized intestinal metaplasia was confirmed in biopsy specimens from 28 of the 33 stained areas (sensitivity 84.8%); in biopsy specimens from 55 of the 60 unstained areas, specialized intestinal metaplasia was not found (specificity 91.7%). In magnified views of methylene blue-positive areas, a tubular, cavernous, or elliptical pattern was seen. Sixteen of 21 men (76.2%) and 3 of 9 women had specialized intestinal metaplasia, and short-segment Barrett's esophagus was diagnosed in these patients. Even in patients with less than 1 cm of columnar-lined esophagus, 8 of 10 stained areas contained specialized intestinal metaplasia (sensitivity 80%) and 23 of 24 unstained areas did not (specificity 95.8%). Six of 12 patients (50%) with less than 1 cm of columnar-lined esophagus had specialized intestinal metaplasia. In total, 19 of 30 patients had specialized intestinal metaplasia. CONCLUSIONS: Magnifying endoscopy with methylene blue selectively detects specialized intestinal metaplasia within short-segment columnar-lined esophagus.     

Detection of intestinal metaplasia in distal esophagus and esophagogastric junction by enhanced-magnification endoscopy

BACKGROUND: Standard videoendoscopy identifies columnar-lined esophagus but cannot distinguish intestinal metaplasia from other types of epithelium. Enhanced-magnification endoscopy identifies different mucosal pit patterns. A preliminary study suggested that a type 3 pattern is associated with the presence of intestinal metaplasia. This study assesses the value of enhanced-magnification endoscopy for the detection of intestinal metaplasia in the distal esophagus and esophagogastric junction in patients undergoing diagnostic EGD. METHODS: Patients undergoing diagnostic endoscopy for upper-GI symptoms underwent enhanced-magnification endoscopy after instillation of 1.5% acetic acid. The enhanced-magnification endoscopy mucosal pattern was classified into 3 types: 1, normal pits; 2, slit-reticular pattern; and 3, gyrus-villous pattern. Preliminary studies indicated that the type 3 pattern was related to intestinal metaplasia. One to 6 biopsies were targeted to areas having a type 3 pattern in columnar-appearing mucosa in the distal esophagus or esophagogastric junction. In the absence of type 3 pattern, one to 8 biopsies were targeted to areas with a type 2 pattern in columnar-appearing mucosa in the distal esophagus or esophagogastric junction. RESULTS: The overall frequency of intestinal metaplasia in the esophagus and esophagogastric junction was 38.8% (26/67 patients). There was a good correlation between the type 3 pattern and intestinal metaplasia in targeted biopsy specimens (sensitivity 88.5%, specificity 90.2%, positive predictive value 85.2%, negative predictive value 92.5%, overall accuracy 90.0%). CONCLUSIONS: Enhanced-magnification endoscopy is useful for detection of intestinal metaplasia in distal esophagus and esophagogastric junction.