Prevalence of eosinophilic esophagitis in patients with gastroesophageal reflux symptoms: A cross-sectional study from a tertiary care hospital in North India

Background

Eosinophilic esophagitis (EoE) is being recognized increasingly all over the globe; Indian data is however sparse. We screened patients with symptoms of gastroesophageal reflux disease (GERD) for presence of EoE in them.

Methods

Consecutive patients with symptoms suggestive of GERD underwent gastroduodenoscopy and esophageal biopsies, obtained from both the upper esophagus (5 cm below the upper esophageal sphincter) and lower esophagus (5 cm above gastroesophageal junction), as well as from any other endoscopically visible abnormal mucosa. Demographic and clinical characteristics, endoscopic findings, peripheral blood eosinophilic count, and history of use of proton-pump inhibitors (PPIs) were analyzed. Stool examination was done to rule out parasitoids. EoE was diagnosed if number of mucosal eosinophil infiltrate was >20 per high-power field. In the latter, Warthin-Starry stain was performed to rule out presence of H elicobacter pylori.

Results

Of 190 consecutive patients with symptoms of GERD screened, esophageal biopsies were available in 185 cases. Of them, 6 had EoE, suggesting a prevalence of 3.2% among patients with GERD. On univariate analysis, history of allergy, non-response to PPI, and absolute eosinophil counts and on multivariable analysis, history of allergy and no response to PPIs were significant predictors of EoE. Presence of EOE did not correlate with severity of reflux symptoms.

Conclusion

In this hospital-based study from northern part of India, prevalence of EoE in patients with GERD was 3.2%. EoE should be considered as a diagnostic possibility, especially in those with history of allergy, no-response to PPI, and absolute eosinophil count of ≥250/cumm.

     

Low Prevalence of Biopsy-Proven Eosinophilic Esophagitis in Patients with Esophageal Food Impaction in Mexican Population

Background

Eosinophilic esophagitis (EoE) is the most common cause of dysphagia and esophageal food impaction (EFI) in the USA, Western Europe, and Australia. In Mexico, the uncomplicated form of this disease is infrequent, and prevalence in patients with EFI is unknown.

Aims

To determine the prevalence and causes of EFI, endoscopic and therapeutic aspects, and establish the prevalence of biopsy-proven EoE in patients with EFI.

Methods

Diagnostic upper gastrointestinal endoscopy reports from January 2011 to December 2016 were retrospectively reviewed. Patients with therapeutic procedures, gastrointestinal hemorrhage, or non-food foreign body impaction were excluded. The number of patients with EFI was determined. Additionally, patients with esophageal biopsy were retained for EoE prevalence calculation. The diagnosis of EoE was defined with the presence of eosinophil infiltration count ≥?15/high-power field with or without typical endoscopic abnormalities.

Results

A total of 4700 reports of the same number of patients were selected; 2209 were males (47%) with a mean age of 57.6?±?12.3 years (range 14–93). We identified 36 patients with EFI (0.76, 95% CI 0.51–1.01), 16 males (44.4%) with a mean age of 54.9?±?19.7 (range 22–92). Esophageal biopsies were obtained in 17/36 (47.2%) cases. The diagnosis of EoE was confirmed in 2 patients (11.7%). Peptic stenosis was the most frequent cause of EFI.

Conclusions

EoE is an infrequent cause of EFI in the Mexican population (11.7%). EoE had the lowest prevalence compared to that reported in Caucasian populations. The prevalence of EFI was also low.

     

Gastro esophageal reflux disease (GERD) prevalence and related risk factors in north of Iran

Background

Gastroesophageal reflux disease (GERD) is one of the most frequent disorders in daily clinical practice with numerous associated consequences. A large number of studies were conducted to determine the prevalence of GERD and its associated risk factors which led to inconsistent results. The present study was performed to evaluate the prevalence of GERD and its related risk factors in north of Iran.

Methods

Nine hundred and thirty-three educated participants aged 18–77 years who had at least a High School Diploma were enrolled in the present study. Validated Persian version of Gastroesopahageal reflux questionnaire was used to collect the data. To determine the GERD associated risk factors, logistic regression was performed.

Results

The prevalence of GERD was 53.5 % (frequent GERD: 12.1 %). Among seven potential risk factors, the positive history of reflux in first relatives (OR = 2.37, CI = 1.76–3.20, p value < 0.001) and asthma (OR = 2.605, CI = 1.553–4.368, p < 0.001) were significantly associated with GERD. Spouse history of GERD in interaction with first relatives history of GERD and smoking was significantly associated with GERD too.

Conclusion

The prevalence of GERD is increasing in our country compared to previus studies, which may lead to serious increment of malignant conditions such as esophagus adenocarcinoma.

     

Gastroesophageal Reflux Disease Might Induce Certain—Supposedly Adaptive—Changes in the Esophagus: A Hypothesis

Background

The increasing prevalence of GERD has become a major concern due to its major health and economic impacts. Beyond the typical unpleasant symptoms, reflux can also be the source of severe, potentially life-threatening complications, such as aspiration.

Aim

Our aim was to support our hypothesis that the human body may in some cases develop various protective mechanisms to prevent these conditions.

Methods

Based on our experiences and review of the literature, we investigated the potential adaptive nature of seven reflux complications (hypertensive lower esophageal sphincter, achalasia, hypertensive upper esophageal sphincter, Zenker’s diverticulum, Schatzki’s ring, esophageal web, and Barrett’s esophagus).

Results

Patients with progressive GERD may develop diverse structural and functional esophageal changes that narrow the lumen of the esophagus and therefore reduce the risk of regurgitation and protect the upper aerodigestive tract from aspiration. The functional changes (hypertensive lower esophageal sphincter, achalasia, hypertensive upper esophageal sphincter) seem to be adaptive reactions aimed at easing the unpleasant symptoms and reducing acid regurgitation. The structural changes (Schatzki’s ring, esophageal web) result in very similar outcomes, but we consider these are rather secondary consequences and not real adaptive mechanisms. Barrett’s esophagus is a special form of adaptive protection. In these cases, patients report significant relief of their previous heartburn as Barrett’s esophagus develops because of the replacement of the normal squamous epithelium of the esophagus by acid-resistant metaplastic epithelium.

Conclusion

We believe that GERD may induce different self-protective reactions in the esophagus that result in reduced acid regurgitation or decreased reflux symptoms.

     

Oral pH in gastroesophageal reflux disease

Aims and Objectives

The aim of this study is to compare surface pH in various parts of the oral cavity between patients with gastroesophageal reflux disease (GERD) and healthy controls.

Methods

Using a flat pH meter sensor, fixed electrode pen type digital pH meter, oral pH levels were assessed at different mucosal sites among 34 GERD patients and 32 healthy controls. Salivary flow rates and buffering capacity were also assessed in them. A thorough oral examination was performed to screen for any oral and dental changes.

Result

A significantly lower pH of 6.65?±?0.13 (mean?±?SD) was found in the GERD group compared to control group 7.23?±?0.12 (p?<?0.05). Least pH was found in the floor of the mouth 6.594?±?0.17 and highest in the lower labial mucosa among the GERD patients. Salivary flow rate and buffering capacity were low in these patients. Significant changes were noticed in the hard and soft tissues of the oral cavity among the GERD group.

Conclusion

Oral mucosal pH is altered in GERD patients and may contribute to effects on the oral cavity.

     

New Developments in the Diagnosis,Therapy, and Monitoring of Eosinophilic Esophagitis

Purpose of review

Eosinophilic esophagitis (EoE) has transformed over the past two decades from a little-known entity to a significant cause of morbidity in the adult and pediatric population. We reviewed the most recent advancements in the diagnosis, therapy, and long-term monitoring of EoE.

Recent findings

Based on clinical, endoscopic, histologic, immunologic, and genetic similarities, there is growing consensus to move away from distinguishing proton pump inhibitor responsive esophageal eosinophilia as an entity distinct from EoE. An increasing number of studies have identified duration of untreated disease as an important determinant of esophageal stricture formation. New approaches to the empiric elimination diet including one, two, four, and step-up protocols were developed to reduce the need for repeated endoscopies during reintroduction of food triggers. Topical steroids remain the mainstay of medical therapy but newer formulations are under development to optimize esophageal delivery. Novel, disease activity monitoring techniques are being evaluated that assess esophageal inflammatory activity without the need for endoscopy.

Summary

Understanding of EoE has increased remarkably from the first identification of the disease. The underlying pathogenesis continues to be explored leading to shifts in diagnostic criteria as well as novel therapeutic targets. Innovative methods to monitor disease are under investigation and more research is needed to understand the natural history of EoE.

     

Speculation as to why the Frequency of Eosinophilic Esophagitis Is Increasing

Purpose of review

The frequency of eosinophilic esophagitis (EoE), an immune/antigen-mediated disorder first described in 1993, has been increasing rapidly. The purpose of this review is to consider hypotheses proposed to explain this increase and to speculate on their validity.

Recent findings

The hygiene hypothesis attributes the rise of EoE to modern hygienic conditions resulting in fewer childhood infections with microbes that might have protected against allergy development. Microbial dysbiosis, a change in the microbiome’s composition and diversity caused by a modern affluent lifestyle, also might contribute to allergic conditions. Environmental factors including modern chemicals contaminating crops, livestock treated with hormones and antibiotics, food additives and processing changes, and pollutants in the air and water conceivably might predispose to EoE. One intriguing hypothesis attributes increasing EoE to increasing use of acid-suppressive medications like proton pump inhibitors, which might prevent peptic digestion of food allergens, increase gastric permeability, and alter the microbiome to favor food allergy development. In a recent pediatric case-control study, use of acid suppressants in infancy was by far the single strongest risk factor identified for later development of EoE.

Summary

It remains unclear which, if any, of the above factors underlies the rising frequency of EoE. These factors need not be mutually exclusive, and the cause of EoE may well be multifactorial.

     

Eosinophilic Esophagitis in Children: Endoscopic Findings at Diagnosis and Post-intervention

Purpose of Review

The goal of this review is to present and summarize studies on endoscopic findings in eosinophilic esophagitis (EoE), at diagnosis and in response to treatment, utilizing rigorous peer-reviewed literature in children wherever possible and to introduce a recently proposed standardized endoscopic evaluation system.

Recent Findings

Gold standard of diagnosis and assessment of response to therapy in EoE requires multiple endoscopies with biopsies for histology, which allows for observation of the esophageal mucosa. Typical endoscopic findings in patients with EoE include edema, exudate, furrowing, concentric rings, and strictures. Endoscopic findings have been broadly characterized into inflammatory features (edema, exudate, furrowing) and fibro-stenotic features (rings, stricture), in order to better reflect their underlying pathophysiology. Recent studies suggest strong correlations between endoscopic findings, through composite scoring systems, and histology, and therefore may be helpful as part of disease surveillance. The EoE Endoscopic Reference Score (EREFS) classification system was proposed in 2013 as an outcome metric for standardization in reporting endoscopic signs of EoE. Subsequent studies support utility of composite scoring, which utility has similarly been seen in pediatric treatment trials.

Summary

Endoscopy in children provides insight into the natural history of EoE, with progressively more fibro-stenotic features occurring over time, giving an additional perspective into esophageal remodeling and response to treatment. Recognition of typical endoscopic findings at diagnosis and upon repeat endoscopy has allowed a clinician to monitor visual changes in esophageal mucosal health. Further studies to assess the role of composite scoring in disease management are needed.

     

Quality Improvement in Gastroenterology: A Systematic Review of Practical Interventions for Clinicians

Background

Quality improvement (QI) identifies practical methods to improve patient care; however, it is not always widely known which QI methods are successful. We sought to create a primer of QI in gastroenterology for the practicing clinician.

Methods

We performed a systematic review of QI literature in gastroenterology. We included search terms for inflammatory bowel disease, irritable bowel syndrome, celiac disease, gastroesophageal reflux disease, pancreatitis, liver disease, colorectal cancer screening, endoscopy, and gastrointestinal bleeding. We used general search terms for QI as well as specific terms to capture established quality metrics for each GI disease area.

Results

We found 33 studies that met our definitions for QI. There were 17 studies of endoscopy including screening colonoscopy, six on liver disease, four on IBD, two on GERD, three on GI bleeding, and one on celiac disease. Education was the most common intervention, although most successful studies combined education with another intervention. Other effective interventions included retraining sessions to reach ADR goals in colonoscopy, nursing protocols to increase HCC screening, and EMR decision support tools to prompt reassessment of PPI therapy. Many studies showed improved compliance to metrics, but few were able to show differences in length of stay, readmissions, or mortality.

Conclusions

Our review of quality improvement literature in gastroenterology revealed common themes of successful programs: Education was frequently used but often insufficient, the EMR may be underutilized in guiding decision making, and patient-reported outcomes were infrequently assessed. Further research may be needed to compare QI strategies directly.

     

Wireless 24, 48, and 96 Hour or Impedance or Oropharyngeal Prolonged pH Monitoring: Which Test,When, and Why for GERD?

Purpose of Review

pH monitoring technologies are routinely utilized in practice to further evaluate symptoms of gastro-esophageal reflux disease and laryngopharyngeal reflux (LPR). This is a review of the recent literature of the available pH monitoring technology and creates an algorithm in the diagnostic work up of a patient with GERD or LPR.

Recent Findings

The catheter-free wireless pH monitor traditionally collects data for 48 h. Recent studies have found that extending to 96 h can be helpful in patients with conflicting results on the first 2 days of the study. In addition, 96 h can allow for testing both on and off of PPI therapy. The oropharyngeal monitoring device is a newer technology that is designed to aid in the diagnoses of LPR. There are limitations with this technology as there is no universal abnormal cutoff and some studies have suggested a poor correlation between multichannel intraluminal impedance-pH (MII-pH) and the oropharyngeal monitoring device. MII-pH has recently developed two additional parameters, the measurement of three 10-min nighttime periods and the post-reflux swallow-induced peristaltic wave (PSPW) index, both of which may increase accuracy of testing.

Summary

Each of these technologies can provide unique data regarding acid reflux exposure in the esophagus and oropharynx. The wireless pH monitor performed off of PPI therapy can help to establish or exclude the diagnosis of GERD. For those patients with refractory symptoms on PPI, MII-pH study can be performed while on therapy and provides data regarding the response to treatment. Oropharyngeal pH monitoring is being utilized in some practices to aid in diagnosis of LPR, but the scientific validity is controversial.

     

Epidermal differentiation complex protein involucrin is down-regulated in eosinophilic esophagitis

Background and aims

Epidermal differential complex (EDC) proteins, such as filaggrin, involucrin, and loricrin, play key roles to protect the mucosal surface against invading pathogens. Eosinophilic esophagitis (EoE) is an allergic gastrointestinal disease that features eosinophilic infiltration of esophageal mucosa, though the function of EDC proteins in its pathogenesis remains unknown. The aim of this study was to investigate possible differences of EDC protein expression in the epithelium of the esophagus, pharynx, and tongue. Furthermore, we examined that expression in esophageal specimens obtained from patients with EoE.

Methods

For evaluating EDC protein expression in epithelium from different locations, we enrolled 72 patients who underwent surgical resection for esophageal, pharyngeal, or tongue squamous cell carcinoma. Pathological samples were used for analysis of expression by immunohistochemistry. In addition, samples were obtained from 10 patients with EoE and 11 healthy subjects, and compared for esophageal epithelial expression of EDC proteins.

Results

In epithelium samples obtained from the esophagus, pharynx, and tongue, the presence of EDC proteins was confirmed by immunohistochemistry analysis findings, though the expression patterns were notably different in comparison to that in epidermis samples. In EoE patients, the expression of involucrin was dramatically down-regulated in esophageal mucosa, whereas down-regulation of filaggrin and loricrin did not reach a statistically significant level.

Conclusion

EDC protein expression was clearly detected in pharyngoesophageal epithelium samples, while that of involucrin alone was markedly reduced in patients with EoE.

     

The Esophageal Microbiome in Health and Disease

Purpose of Review

Investigation of the esophageal microbiome is a relatively new field. This review will outline data characterizing the esophageal microbiome in both health and disease states, including gastroesophageal reflux disease (GERD), Barrett’s esophagus, esophageal cancer, eosinophilic esophagitis, and motility disorders.

Recent Findings

While the esophagus was previously considered devoid of a significant bacterial population, development of culture-independent techniques, specifically 16S rRNA gene sequencing, as well as novel, minimally invasive microbial sampling modalities, has facilitated characterization of the esophageal microbiome in both health and several disease states. Although limited, there is evidence that the esophagus contains a diverse microbial population, with Gram-positive bacteria, specifically Streptococcus, dominating in health, while Gram-negative bacteria prevail in reflux disorders including GERD and Barrett’s esophagus. The microbiome is altered with other esophageal disorders as well, including eosinophilic esophagitis and esophageal motility disorders, though these changes have been less well characterized.

Summary

Characterization of the gut microbiome has advanced significantly; however, further investigation is essential. Understanding changes in the esophageal microbiome could affect our understanding of the natural history of diseases of the esophagus and present potential therapeutic approaches.

     

Poor inter-observer agreement on the endoscopic diagnosis of eosinophilic esophagitis among Japanese endoscopists

Background

A variety of endoscopic findings are considered useful for the diagnosis of eosinophilic esophagitis (EoE). However, the diagnostic consistency among Japanese endoscopists for those findings has not been fully examined. The aim of this study was to investigate the inter- and intra-observer agreement for endoscopic findings suggesting EoE.

Methods

Forty endoscopists, including 20 with board certification from the Japan Gastroenterological Endoscopy Society (JGES), participated in this study. Initially, they examined 50 randomized white-light endoscopic images from 30 patients with EoE and 20 without EoE. Four weeks later, the same 50 endoscopic images were re-examined in a different random order. Inter- and intra-observer agreement was calculated using kappa statistics for multiple observers.

Results

The kappa coefficient of reliability [95% confidence interval (CI)] for all 40 endoscopists for diagnosis of EoE was 0.34 (0.33–0.35), indicating poor level of inter-observer agreement, while intra-observer agreement showed a moderate value of 0.52 (0.47–0.57). Among 4 possible endoscopic findings (linear furrows, concentric rings, edema, white exudates) for EoE, acceptable levels (kappa value >0.4) of inter- and intra-observer agreement were seen only for linear furrows. When the JGES board-certified and non-certified endoscopists were compared for successful diagnosis of EoE, the value was significantly higher for the board-certified group. However, the level of inter-observer agreement remained poor level.

Conclusion

We concluded that inter-observer agreement on the endoscopic diagnosis of EoE among Japanese endoscopists did not reach a clinically acceptable level.

     

The Proton Pump Inhibitor Nonresponder: a Behavioral Approach to Improvement and Wellness

Purpose of Review

Gastroesophageal reflux disease (GERD) is a difficult to treat medical condition, where nearly 40% of patients are refractory to standard medical intervention, which typically begins with a proton pump inhibitor (PPI). These PPI nonresponders represent a population of patients, where treatment planning must be individualized; multidisciplinary and psychiatric comorbidities should be considered. This review highlights treatment options that include neuromodulators, lifestyle, and psychological interventions for the PPI nonresponder.

Recent Findings

Mental health specialists in the field of psychogastroenterology can aid in the management of esophageal hypersensitivity, which can drive the symptom experience of a PPI nonresponder. Considerations for comorbid anxiety and depression in this population require careful assessment and treatment.

Summary

Physicians are encouraged to create realistic expectations for symptom management and offer multidisciplinary options for treatment early in care. Patients will frequently benefit from working with a GI psychologist and find value in behavioral interventions.

     

Vascular Genetics: Presentations,Testing, and Prognostics

Purpose of review

Numerous studies have begun to unravel the genetic basis of not only aortic disease but also other forms of commonly encountered vascular diseases. The goal of this review is to provide clinicians a reference to help identify and diagnose different types of vascular disease with a genetic underpinning.

Recent findings

Ongoing studies have identified numerous genes involved in the TGF-β signaling pathway that are also associated with thoracic aortic aneurysm and dissection, and it is possible to test for pathogenic variants in these genes in the clinical setting using commercially available genetic testing panels. Additional studies have begun to identify genetic variants associated with an increased risk of bicuspid aortic valve, abdominal aortic aneurysm, and fibromuscular dysplasia.

Summary

With increased availability of low-cost genetic testing, clinicians are now able to not only definitively diagnose some vascular syndromes but also provide information on the risk of disease in other family members, as well as provide guidance in terms of family planning. As the cost of genetic testing continues to drop with the benefit of increasing insurance coverage, genetic data will increasingly become part of clinical care for many patients with vascular disease.

     

Molecular Diagnostic Testing in Cardiac Transplantation

Purpose of Review

Acute rejection is one of the most feared complications of cardiac transplantation. Developing non-invasive methods for detection and surveillance of acute rejection have long been a goal for post-transplant care.

Recent Findings

Here, we will review molecular diagnostic tests that are currently in use or under development to diagnose acute cellular rejection after cardiac transplantation.

Summary

Gene expression, microRNA, molecular microscope, and cell-free DNA assays offer non-invasive alternatives to the endomyocardial biopsy for acute rejection surveillance.

     

Management of Esophageal Food Impaction Varies Among Gastroenterologists and Affects Identification of Eosinophilic Esophagitis

Background and Aims

Esophageal food impaction (EFI) is a gastrointestinal emergency requiring immediate evaluation in the emergency room (ER) and an esophagogastroduodenoscopy (EGD) for disimpaction. EFI is also a distinct presenting feature of eosinophilic esophagitis (EoE). This study aimed at understanding the management of EFI among gastroenterologists (GIs) and estimated its impact on identification of EoE in USA.

Methods

GIs associated with three major gastroenterology societies based in USA were invited to participate in a web-based survey. Information on the resources available and utilized, and the clinical decision-making process related to management of EFI cases was collected and analyzed.

Results

Of 428 responses, 49% were from pediatric GIs, 86% practiced in the USA, and 78% practiced in an academic setting. Compared to the pediatric GIs, adult GIs were more likely to perform EGD in the emergency room [OR 87.96 (25.43–304.16)] and advance the food bolus into stomach [5.58 (3.08–10.12)]. Only 34% of respondents obtained esophageal biopsies during EGD, and pediatric GIs were more likely to obtain esophageal biopsies [3.49 (1.12–10.84)] compared to adult GIs. In USA, by our conservative estimates, 10,494 patients presenting to ER with EFI and at risk of EoE are likely being missed each year.

Conclusions

EFI management varies substantially among GIs associated with three major gastroenterology societies in USA. Based on their practice patterns, the GIs in USA are likely to miss numerous EoE patients presenting to ER with EFI. Our findings highlight the need for developing and disseminating evidence-based EFI management practice guidelines.

     

Use of self-expandable plastic stents (SEPS) in management of refractory benign esophageal strictures: a single center experience

Back ground

Benign esophageal stricture is a common cause for dysphagia in adults. It can negatively affect the quality of patient’s life and may cause many complications. Benign esophageal strictures are caused by different procedures and disorders, such as gastroesophageal reflux disease, post-surgery anastomotic stricture, radiation, ablative therapy or caustic ingestion. The aim of the study was to assess the efficacy of Polyflex stent insertion in refractory benign esophageal strictures in patients admitted to the endoscopy unit of the Medical Research Institute hospital, Alexandria University, Alexandria, Egypt.

Patients and methods

Polyflex, self-expandable plastic stent, were inserted in nine patients with refractory benign esophageal strictures with follow-up for 1 year.

Results

Dysphagia was significantly improved in 88% of patients, after insertion of Polyflex stents. Complications reported were one patient with stent migration and 2 patients with esophageal ulceration.

Conclusion

The use of Polyflex stents in the management of benign refractory esophageal strictures appears to be promising with high clinical success rate and few manageable complications.

     

Factors Associated with HIV Testing among African American Female Adolescents in Juvenile Detention Centers

Background

Little is known about sexual and psychosocial factors associated with HIV testing among detained African American female adolescents—an understudied group at risk for HIV.

Methods

188 detained African American female adolescents completed assessments on HIV testing, sexual risk behaviors, and psychosocial factors.

Results

Unprotected vaginal sex, history of STI-positivity or pregnancy, higher STI knowledge, and lower partner availability were associated with a higher likelihood of ever being tested for HIV.

Discussion

HIV testing is the gateway to important services for high-risk HIV-positive and HIV-negative adolescents. More research is needed to address barriers and to inform programmatic changes to increase testing among youth.

     

Endocytoscopic observation of various types of esophagitis

Background

Use of an endocytoscopy system (ECS) makes it possible to omit biopsy histology for esophageal squamous cell carcinoma (ESCC). However, for differential diagnosis of ESCC, the endocytoscopic characteristics of esophagitis should be clarified.

Methods

We examined the morphology of surface cells in 20 cases of gastroesophageal reflux disease (GERD) (Grade M: 6 cases, A: 5 cases, B: 1 cases, C: 4 cases, D: 4 cases), five cases of candida esophagitis, and one case of eosinophilic esophagitis. One endoscopist classified the lesions using the modified type classification, and one pathologist judged the endocytoscopy images as “neoplastic”, “borderline”, or “non-neoplastic”.

Results

All cases of Grade M, A, and B GERD were classified as “type 1 or 2” by the endoscopist. However, 3/8 Grade C and D GERD lesions that had been diagnosed as regenerative squamous epithelium from biopsy histology were diagnosed as Type 3. All Grade M, A, and B cases were interpreted by the pathologist as “non-neoplastic”, whereas 4/8 Grade C and D GERD lesions, including three cases of regenerating epithelium, were diagnosed as “borderline” on the basis of ECS images. In 80 % of candida esophagitis cases, hyphae were visualized as white areas. Eosinophilic esophagitis showed a slight increase of cell density with marked infiltration of inflammatory cells.

Conclusion

Some cases of severe GERD cannot be clearly distinguished from esophageal squamous cell carcinoma (ESCC) using ECS, and therefore at present, cases of ESCC coexisting with severe GERD should not be diagnosed by ECS alone and probably require biopsy. (UMIN000007627).