Esophageal acid sensitivity in Barrett's esophagus

Esophageal acid sensitivity was evaluated in 15 patients with Barrett's esophagus and in 15 patients with reflux esophagitis uncomplicated by Barrett's. Patients with Barrett's esophagus had sensitivity to esophageal acid perfusion less frequently than those with uncomplicated reflux esophagitis (66 vs. 100%; p less than 0.05). Moreover, patients with Barrett's esophagus with acid sensitivity took longer to develop pain during acid perfusion (p less than 0.05), and overall, experienced less severe symptoms (p less than 0.01) than those with reflux esophagitis. Over a 2-week period, as judged by diary, the Barrett's group had less frequent (p less than 0.01) and less severe (p less than 0.01) heartburn symptoms than the other patients. These results indicate that patients with Barrett's esophagus have significantly reduced esophageal acid sensitivity and, as a consequence, have an impaired ability to recognize acid reflux.     

Barrett's esophagus: prevalence and size of hiatal hernia

OBJECTIVE: Barrett's esophagus is caused by gastroesophageal reflux and predisposes to adenocarcinoma. Hiatal hernia may cause reflux. The prevalence and size of hernias in patients with Barrett's esophagus was investigated. METHODS: Axial hernia length and the width of the diaphragmatic hiatus were measured prospectively at endoscopy. RESULTS: A 2-cm or longer hernia was found in 96% of 46 patients with Barrett's esophagus, in 42% of 103 controls (p < 0.001), and in 72% of 18 patients with short segment Barrett's esophagus (p < 0.05 vs controls). A hernia was found in 71% of 31 controls with esophagitis and in 29% of 72 controls without esophagitis (p < 0.001). Of 54 controls with neither esophagitis or reflux symptoms, 20% had a hernia. Mean hernia length was 3.95 cm in Barrett's esophagus, and 2.81 cm in controls (p < 0.005). Mean hiatus width was 3.52 cm in patients with Barrett's esophagus and hernia, and 2.24 cm in controls with hernia. Hernia length was similar in patients with and without esophagitis, and in short segment Barrett's esophagus. CONCLUSIONS: Most patients with Barrett's esophagus have hiatal hernia; their hernias are longer and the hiatal openings wider than in controls with or without esophagitis. Hiatal hernia likely contributes to the development of Barrett's esophagus.     

The prevalence of Helicobacter pylori infection and the status of gastric acid secretion in patients with Barrett's esophagus in Japan

OBJECTIVES: The acidity of the refluxate into the esophagus is a key factor for the pathogenesis of gastroesophageal reflux disease. Helicobacter pylori (H. pylori) infection can influence gastric acid secretion. We have reported that H. pylori infection prevents reflux esophagitis by decreasing gastric acid secretion in Japanese patients, but the role of this organism in Barrett's esophagus is unclear. The aim of this study was to investigate the prevalence of H. pylori infection and gastric acid secretion in Japanese patients with reflux esophagitis with or without Barrett's esophagus. METHODS: We enrolled 112 reflux esophagitis patients who were examined for the status of H. pylori and acid secretion in this study. They were divided into three groups, according to the presence or absence of Barrett's esophagus as follows: reflux esophagitis group without Barrett's esophagus (reflux esophagitis alone) (80 patients); short-segment Barrett's esophagus group (16 patients); and long-segment Barrett's esophagus group (LSBE) (16 patients). Age- and sex-matched control subjects were also assigned to the 80 patients with reflux esophagitis alone. The prevalence of H. pylori infection was determined by histology, rapid urease tests, and serum IgG antibodies. Gastric acid secretion was evaluated by the endoscopic gastrin test (EGT). RESULTS: The overall prevalence of H. pylori infection in the reflux esophagitis patient group (24.1%) was significantly lower than the control group (71.2%) (odds ratio 0.13, 95% confidence interval 0.07-0.24; p < 0.0001). The prevalence of H. pylori infection in the patients with Barrett's esophagus tended to be lower than that in the patients with reflux esophagitis alone (reflux esophagitis alone; 30.0%, SSBE; 18.7%, LSBE; 0%), especially in the patients with LSBE compared with the reflux esophagitis alone group (p < 0.01). The EGT value of the respective reflux esophagitis patient group was significantly higher than the control group. The EGT value in the patients with Barrett's esophagus tended to be higher than that in the patients with reflux esophagitis alone, but the difference was not statistically significant. When examined in H. pylori-negative subjects, no difference was found in the EGT value between the control subjects and the patients with reflux esophagitis alone, but it was significantly higher in patients with Barrett's esophagus than the control subjects (p < 0.05). On the other hand, when examined in the H. pylori-positive subjects, the EGT value was significantly higher in the patients with reflux esophagitis alone than in the control subjects (p < 0.01). CONCLUSIONS: H. pylori infection may play a protective role in the development of Barrett's esophagus, especially in the development of LSBE in Japan. Gastric acid hypersecretion may be concerned with the development of Barrett's esophagus in addition to the absence of H. pylori infection.     

Is Barrett's esophagus characterized by more pronounced acid reflux than severe esophagitis?

Objective: Barrett's esophagus is related to gastroesophageal reflux disease (GERD). However, only a small fraction of patients with GERD develop Barrett's esophagus. We evaluated whether gastroesophageal acid reflux is more pronounced in Barrett's patients than in patients with moderate or severe endoscopic esophagitis.
Methods: Retrospective evaluation of results of esophageal manometry and 24 hour ambulatory pH monitoring performed between 1990 and 1996 at the Leiden University Medical Center in those patients who also underwent endoscopy ≤3 months before pH-metry. Included were 51 patients with Barrett's esophagus, 30 patients with severe esophagitis, 45 patients with moderate esophagitis, and 24 healthy control subjects.
Results: Patients with Barrett's esophagus had significantly increased acid reflux time (   p < 0.01  –0.05) compared to patients with moderate, but not compared to patients with severe esophagitis. Distal esophageal body motility and LES pressure were significantly (   p < 0.01  –0.05) reduced in patients with Barrett's esophagus compared to patients with moderate esophagitis but not compared to those with severe esophagitis.
Conclusion: Although acid reflux is increased in patients with Barrett's esophagus and esophageal motility is impaired, other factors apart from acid exposure and motility contribute to the development of Barrett's esophagus.     

Gastroesophageal Reflux Disease in the Elderly: More Severe Disease That Requires Aggressive Therapy

Objective: To evaluate gastroesophageal reflux disease in the elderly (people ≥ 60 yr). Methods: Basal gastric-acid secretion was prospectively determined in 228 consecutive patients with symptomatic gastroesophageal reflux disease who had upper gastrointestinal endoscopy and were diagnosed with either pyrosis alone (n = 98), erosive esophagitis (n = 87), or Barrett's esophagus (n = 43). Results: Patients ≥ 60 yr (n = 66) had significantly more esophageal mucosal disease (erosive esophagitis, Barrett's esophagus) than patients < 60 yr (n = 162)- 81% versus 47% ( p = 0.000002, Fisher's exact test). Furthermore, 87% of patients ≥ 70 yr had esophageal mucosal disease. For each decade from < 30 yr to ≥ 70 yr, there was a significant increase in esophageal mucosal disease ( p = 0.002; X ² test, 23.96); however, there were no significant differences in severity of pyrosis symptoms or in mean basal acid output for each decade. When 146 of the 228 patients with gastroesophageal reflux disease were given enough ranitidine (mean, 630 mg/d; range, 300–3000 mg/d) for the relief of all pyrosis symptoms and healing of all esophageal mucosal disease, there were no significant differences in ranitidine therapy between each decade. Conclusions: Elderly patients with pyrosis symptoms severe enough to require upper gastrointestinal endoscopy have gastroesophageal reflux disease with more esophageal mucosal disease (erosive esophagitis, Barrett's esophagus) than patients < 60 yr, and like younger patients, may require markedly increased doses of ranitidine as large as 2400 mg/d for effective therapy.     

Specialized intestinal metaplasia of the distal esophagus in gastroesophageal reflux disease: prevalence and clinico-demographic features

BACKGROUND: Specialized intestinal metaplasia can be categorized according endoscopic and histological findings in long segment Barrett, short segment Barrett and specialized intestinal metaplasia of cardia. Barrett's esophagus is an acquired disease that is found in about 10%-13% of patients undergoing endoscopy for symptoms of gastroesophageal reflux disease and it is well established as predisposing to esophageal adenocarcinoma. The columnar epithelium with goblet cells replaces the normal squamous epithelium. OBJECTIVE: To determine the prevalence and clinical-demographic characteristics of specialized intestinal metaplasia of distal esophagus in the gastroesophageal reflux disease. METHODS: From April to October 2002, 402 patients referred to upper endoscopy due gastroesophageal reflux disease were evaluated through of a symptom questionnaire about clinical and demographic features and submitted to upper endoscopy with four-quadrant biopsies 1 cm below escamocolumnar junction. RESULTS: Eighteen point four percent of patients had specialized intestinal metaplasia, 0.5% long segment Barrett esophagus, 3.2% short segment Barrett's esophagus and 14.7% specialized intestinal metaplasia of cardia. Patients with Barrett's esophagus showed a tendency to be male and specialized metaplasia of cardia to be female. All patients with Barrett's esophagus were white. There was not association between symptoms of gastroesophageal reflux disease and specialized intestinal metaplasia, but patients with Barrett's esophagus showed a tendency to have symptoms over 5 years and had more hiatal hernia and esophagitis. The use of alcohol and tobacco was not related to the presence of specialized intestinal metaplasia. CONCLUSIONS: Barrett's esophagus was more related to the male gender, gastroesophageal reflux disease symptoms for 5 years or longer, more intense esophagitis and hiatal hernia, but was not related to the use of tobacco and alcohol.     

Barrett's esophagus: prevalence in symptomatic relatives

OBJECTIVES: Relatives of patients with Barrett's esophagus have an increased prevalence of reflux symptoms. Our aim was to find if these relatives were at increased risk of having Barrett's esophagus. METHODS: First degree relatives of patients with Barrett's esophagus completed the Reflux Symptom Questionnaire. Relatives with reflux symptoms, never previously investigated. were invited for endoscopy. Controls were patients with similar reflux symptoms and no family histories of Barrett's esophagus. RESULTS: We found previously undiagnosed Barrett's esophagus (>3 cm) in eight of 100 relatives (8%) from 53 families and in five of 100 controls (5%) (adjusted OR = 1.58, 95% CI = 0.46-5.45). Including another 27 previously investigated cases, 10 of the 53 families had two or more cases of Barrett's esophagus. Barrett's esophagus prevalence increased with age (p = 0.014) and was associated with reflux symptoms of >10 yr (p = 0.020), and Barrett's esophagus was twice as common in males (p = 0.28). Reflux esophagitis was found in 74% of relatives and 57% of controls without Barrett's (p = 0.04). CONCLUSIONS: The risk of Barrett's esophagus in any one symptomatic relative of a patient with Barrett's esophagus was not statistically higher than in other persons with reflux symptoms. However, more relatives of Barrett's esophagus patients have reflux symptoms, so the overall prevalence of Barrett's esophagus and reflux esophagitis in relatives may also be greater than in the general population. In considering whether to screen patients with reflux symptoms for Barrett's esophagus, age and duration of symptoms are stronger predictors than having a relative with Barrett's esophagus.     

Familial clustering of reflux symptoms

OBJECTIVE: A number of case reports describe multiple family members with gastroesophageal reflux disease and Barrett' s esophagus. The wider importance of familial factors in gastroesophageal reflux disease has not been established. Therefore, we have studied the prevalence of reflux symptoms and medication use among relatives of patients with documented gastroesophageal reflux disease. METHODS: A postal questionnaire study of the first degree relatives of six groups of matched patients. The groups comprised patients with 1) no dyspeptic symptoms; 2) reflux symptoms and a normal pH study; 3) reflux symptoms, an abnormal pH study, and a lower esophageal sphincter (LOS) pressure more than 10 mm Hg; 4) reflux symptoms, an abnormal pH study, and a LOS pressure less than 10 mm Hg; 5) Barrett's esophagus; and 6) peptic stricture. RESULTS: Four hundred eighteen subjects replied (78% response). Infrequent reflux symptoms were equally common in all groups of relatives. Frequent reflux symptoms, however, were more common among relatives of patients with an abnormal pH study and normal (26%, p = 0.007) or low LOS pressure (27%, p = 0.01) or Barrett's esophagus (30%, p = 0.003), compared with relatives of nondyspeptic patients (9%). Frequent reflux symptoms were no more common among relatives of patients with a normal pH study (16%) or peptic stricture (18%). Reflux medication use showed a similar pattern. CONCLUSIONS: Familial clustering of reflux symptoms is seen in relatives of patients with reflux symptoms and increased esophageal acid exposure and in relatives of patients with Barrett's esophagus.     

Prevalence of Barrett's esophagus by endoscopy and histologic studies: a prospective evaluation of 306 control subjects and 376 patients with symptoms of gastroesophageal reflux

The classic endoscopic diagnosis of a Barrett's esophagus (BE) is based on the finding of > or =3 cm, of distal esophagus covered by specialized columnar epithelium. However, currently, it is based on the finding of intestinal metaplasia (IM) at the squamous-columnar mucosal junction, independent of its extent. The aim of this study was to determine the prevalence of Barrett's esophagus by endoscopic and histological findings in control subjects and in patients with symptoms of gastroesophageal reflux (GER). Three hundred and six control subjects and 376 patients with symptoms of gastroesophageal reflux were included in this prospective study. Patients with Barrett's esophagus were classified in three groups as follows. 1. Intestinal metaplasia at the cardia. When endoscopy showed non-Barrett's esophagus, but histological intestinal metaplasia was found. 2. Short-segment Barrett's esophagus. When <3 cm, was covered with tongues or finger-like or creeping substitution of distal esophagus. 3. Long-segment Barrett's esophagus. When > 3 cm, of distal esophagus was covered by specialized columnar epithelium. Two biopsies at the antrum, four biopsies at the squamous-columnar junction and one or two at the distal esophagus were taken. In control subjects, 1.6% showed histological IM at the esophagogastric junction. In patients with GER without esophagitis or with erosive esophagitis, IM was found in 18% and 10.7% respectively. 'Short-segment' Barrett's esophagus was three times more frequent than 'long-segment' Barrett's esophagus. Patients with Barrett's esophagus were significantly older than the other groups. The presence of complications or erosions, peptic ulcer or stricture were significantly more frequent among patients with 'long-segment' Barrett's esophagus (p < 0.0001). The prevalence of dysplasia was similar in all groups of patients with Barrett's esophagus. Complications such as ulcers, stricture and dysplasia were exclusively seen among patients with BE, whereas non-Barrett's patients did not exhibit these complications. In control subjects, IM can be found in a low percentage of cases. Among patients with symptoms of GER, the classic endoscopic diagnosis of a Barrett's esophagus can underestimate this condition in 80% of the cases. Patients with intestinal metaplasia at the cardia already present 17% of the cases with low-grade dysplasia. In all patients with symptoms of GER, systematic biopsies at the squamous-columnar junction should be taken.     

Increased acid and bile reflux in Barrett's esophagus compared to reflux esophagitis, and effect of proton pump inhibitor therapy

OBJECTIVES: Barrett's metaplasia is an acquired condition resulting from longstanding gastroesophageal reflux disease. Approximately 10% of esophagitis patients develop Barrett's esophagus. There is increasing evidence that duodenogastroesophageal reflux plays a role in the progression of disease. We further analyzed the correlation of acid and biliary reflux with reflux esophagitis and Barrett's esophagus and tested the effects of proton pump inhibitor therapy. METHODS: Patients with either reflux esophagitis (group 1) or Barrett's esophagus (group 2) prospectively underwent simultaneous 24-h esophageal pH and bile reflux testing without any therapy affecting acid secretion or GI motility. A total of 16 patients in group 1 and 18 patients in group 2 were tested again under proton pump inhibitor therapy. RESULTS: Acid and bile exposure were significantly increased in Barrett's patients (n = 23) compared to 20 esophagitis patients (median percentage of time that pH was <4 was 24.6% vs 12.4%, p = 0.01, median percentage of time that bilirubin absorbance was >0.2 was 34.7% vs 12.8%, p < 0.05). During therapy, both acid and bile reflux decreased significantly in both groups. Median percentage of time that pH was <4 and bilirubin absorbance was >0.2 before and during therapy was 18.2%/2.3% and 29.8%/0.7% (p = 0.001 and p = 0.001) in Barrett's esophagus patients versus 14.5%/3.6% and 21.5%/0.9% (p = 0.002 and p = 0.011) in esophagitis patients. There was no significant difference between the groups. In two esophagitis patients, bile reflux increased during therapy. CONCLUSIONS: There is a good correlation of the duration of esophageal exposure to acid and bile with the severity of pathological change in the esophagus. Both acid and bile reflux is significantly suppressed by proton pump inhibitor therapy with exceptions among individual esophagitis patients. The prolonged simultaneous attack of bile and acid may play a key role in the development of Barrett's metaplasia.     

Technetium pertechnetate esophageal imaging for detection of Barrett's esophagus

This study was designed to evaluate the utility of 99mTc pertechnetate esophageal scintigraphy for identifying Barrett's esophagus. Seventeen patients with Barrett's esophagus and seven patients with reflux esophagitis were studied. Eight of 17 patients with Barrett's esophagus had a positive image (sensitivity 47%). In contrast, none of the seven patients with esophagitis had a positive image (specificity 100%). Pentagastrin did not have a significant effect on the sensitivity. There was no correlation between the type of Barrett's epithelium and the sensitivity of the imaging results. However, the test is more frequently positive in those patients with more extensive disease. Our study indicates that technetium pertechnetate imaging should not be used as a screening test for the detection of Barrett's esophagus in patients with symptoms of gastroesophageal reflux, as the negative predictive value of the test is limited.     

The yield of upper gastrointestinal endoscopy in patients with suspected reflux-related chronic ear, nose, and throat symptoms

OBJECTIVES: It is well established that various ENT disorders and symptoms may be a manifestation of gastroesophageal reflux disease (GERD). Erosive esophagitis is considered a rare finding in ENT patients and therefore upper gastrointestinal (GI) endoscopy is not recommended in the diagnostic work-up. However, large prospective studies underscoring this policy are lacking. The aim of the present study was to investigate the prevalence and severity of esophagitis in patients with suspected GERD-related chronic ENT symptoms. METHODS: Endoscopy was performed in 405 ENT patients with suspected GERD and 545 typical GERD patients. The presence of erosive esophagitis, Barrett's esophagus, hiatal hernia, peptic ulcer, and Helicobacter pylori infection on biopsies was determined and compared with the results of a symptom questionnaire. RESULTS: The prevalence of erosive esophagitis (52.3% vs 38.4%; p < 0.05), mainly grade 1 (31.9% vs 22.7%; p < 0.05), and of peptic ulcer (8.4% vs 4.3%; p < 0.05) was significantly higher in patients with GERD-related ENT symptoms compared to typical GERD. Barrett's mucosa occurred in, respectively, 4.9% and 4.5% of the patients (NS). Esophagitis prevalence was highest in patients with predominant cough and lowest in globus pharyngeus and throat symptoms. The presence of esophagitis was associated with significantly higher rates of symptom relief during the first 8 wk of proton pump inhibitor (PPI) therapy. CONCLUSIONS: Patients with suspected GERD-related ENT symptoms have a high prevalence of esophagitis and this is associated with better response to antisecretory therapy.     

The value of medical imaging in uncomplicated and complicated Barrett's esophagus

Barrett's esophagus is an acquired condition characterized by a progressive columnar metaplasia of the distal esophagus caused by longstanding gastroesophageal reflux and reflux esophagitis. Barrett's esophagus is a premalignant condition associated with a significantly increased risk of developing esophageal adenocarcinoma. The purpose of this article is to provide an overview of the radiologic aspects of Barrett's esophagus and esophageal adenocarcinoma. Review of the literature shows that some findings on esophagography that are relatively specific for Barrett's esophagus are not sensitive, while others that are sensitive have a low specificity. Specific radiologic features allowing a confident diagnosis of Barrett's esophagus are a high esophageal stricture or ulcer associated with a hiatal hernia and/or gastroesophageal reflux. A reticular mucosal pattern is a relatively specific sign particularly if located adjacent to a stricture and is highly suggestive of Barrett's esophagus. Unfortunately, these findings are only present in a minority of cases. More common but nonspecific findings include gastroesophageal reflux, hiatal hernia, reflux esophagitis and/or peptic stricture in distal esophagus. These findings may also be present in patients with uncomplicated reflux disease. Barrett's esophagus carries a risk of malignant change. Early adenocarcinoma may appear as a plaque-like lesion or with focal irregularity, nodularity, and ulceration of the esophageal wall. Invasive adenocarcinoma may be seen as an infiltrating ulcerated mass. The radiologic diagnosis of Barrett's esophagus is limited by lack of criteria that are both sensitive and specific. The major value of double-contrast esophagography is its ability to classify patients into high risk (high stricture, ulcer or reticular pattern), moderate risk (esophagitis and/or distal peptic strictures), and low-risk (absence of esophagitis or stricture) for Barrett's esophagus determining the relative need for endoscopy and biopsy. Endoscopy and biopsy are generally advocated to make a definitive diagnosis. Endoscopic ultrasound plays a role in the early detection of invasive carcinoma and the staging of proven carcinoma but has no role in the surveillance of Barrett's esophagus.     

Study of the influence of hiatus hernia on gastroesophageal reflux

AIM: To explore whether the presence of a sliding hiatus hernia influences gastroesophageal reflux.METHODS: Endoscopy and 24 h pH monitoring were performed for 197 outpatients with gastroesophageal reflux symptoms.RESULTS: Of the 197 patients with symptoms of gastroesophageal reflux, patients with hiatus hernia accounted for 36%. The incidence of esophagitis in patients with hiatus hernia was significantly higher than that in patients without hiatus hernia. The results of 24 h pH monitoring showed that 84 patients had physiological reflux, 37 had pathological reflux without esophagitis, 64 had reflux esophagitis and 12 had physiological reflux concomitant with esophagitis. All the patients with hiatus hernia had a longer percentage time with supine reflux and a higher frequency of episodes lasting over 5 min at night compared to those without hiatus hernia. The incidence of combined daytime and nocturnal reflux in patients with hiatus hernia was significantly higher than that in patients without hiatus hernia.CONCLUSION: Pathological reflux and reflux esophagitis in some patients with symptoms of gastroesophageal reflux represent two different stages of gastroesophageal reflux disease. Pathological reflux is the first stage, in which the lower esophageal sphincter is incompetent but the esophageal mucosal resistance effectively prevents regurgitated acid from damaging the esophageal mucosa. Reflux esophagitis represents the second stage, in which the aggression of the regurgitated acid is so strong that the esophageal mucosa fails to resist it and the epithelium of the esophagus is damaged. Patients with hiatus hernia have a high incidence of combined daytime and nocturnal reflux, with the latter being responsible for esophagitis.     

Quantification of gastro-esophageal reflux in Barrett's esophagus

In the present paper we analyze the importance of gastro-oesophageal reflux in 20 patients with Barrett's oesophagus and in 20 patients with esophagitis without Barrett's mucosa; ten of this last group had mild esophagitis and ten severe inflammatory changes. In all the cases the oesophageal pH was measured during 24 hours; the results showed that although the reflux was more important in the group of patients with Barrett's esophagus than in the whole group of patients with esophagitis without Barrett's esophagus, figures were similar in the group with severe oesophagitis and the group with Barrett's oesophagus. We conclude that the pathogenesis of Barrett's esophagus includes factors other than gastroesophageal reflux.     

Gastroesophageal Reflux and Barrett''s Esophagus in Developmentally Disabled Patients

Twenty-seven patients from an institution for the developmentally disabled underwent endoscopy for evaluation of vomiting, regurgitation, rumination, or upper gastrointestinal bleeding. The presence of gastroesophageal reflux and Barrett's esophagus was determined retrospectively. Twenty-three patients had an IQ less than 20, 19 were nonambulatory, and 14 were taking at least one neuroleptic drug daily. Seven patients (26%) had histologically documented Barrett's esophagus of the specialized-columnar type. Two patients with Barrett's esophagus had benign esophageal strictures, but no cases of adenocarcinoma were found. There were no significant differences (p greater than 0.05) between patients with or without Barrett's esophagus in regard to symptoms, age, sex, IQ, medications, or ambulatory status. The present data suggest that Barrett's esophagus may frequently occur in developmentally disabled patients with symptoms and signs of gastroesophageal reflux.     

Characteristics of intestinal metaplasia in the gastric cardia

OBJECTIVE: Intestinal metaplasia of the gastroesophageal junction is frequently grouped together with Barrett's esophagus. The area of the gastroesophageal junction is comprised of the distal esophagus and the gastric cardia. The aim of the present study was to assess whether intestinal metaplasia in the distal esophagus and gastric cardia represent two different entities with a different set of risk factors. METHODS: Patients presenting for elective upper endoscopy were enrolled into a prospective study. The presence of gastritis and intestinal metaplasia was evaluated in gastric biopsies taken from the antrum, corpus, and cardia. Barrett's esophagus was defined by the presence of any length of columnar mucosa above the gastroesophageal junction. RESULTS: Of 302 patients, 50 patients had intestinal metaplasia of the gastric cardia, 73 Barrett's esophagus, and 116 erosive esophagitis. Men were more prone than women to develop Barrett's esophagus or erosive esophagitis. Both conditions were also more common among whites than nonwhites. Smoking was particularly common among patients with Barrett's esophagus. Patients with cardiac intestinal metaplasia did not share these demographic characteristics. The prevalence of daily reflux symptoms, erosive esophagitis, and Barrett's esophagus was similar among patients both with and without cardiac intestinal metaplasia. However, atrophy and intestinal metaplasia of the gastric antrum and corpus were found more frequently among patients with than without cardiac intestinal metaplasia. CONCLUSIONS: Intestinal metaplasia of the gastric cardia is different from Barrett's esophagus. Although cardiac intestinal metaplasia is closely associated with signs of gastritis in other parts of the stomach, gastroesophageal reflux disease does not seem to be a risk factor. A diagnosis of Barrett's esophagus should not be made based on the presence of intestinal metaplasia within the cardiac portion of the gastroesophageal junction.     

Gastroesophageal reflux and Barrett's esophagus in adults born with esophageal atresia

OBJECTIVE: Postoperative morbidity after correction of esophageal atresia is partly determined by gastroesophageal reflux disease, which has been proven to affect from one-half to two-thirds of patients during childhood. We conducted a follow-up study to test our hypothesis that, if former patients still show gastroesophageal reflux at adult age, they are at high risk for developing Barrett's esophagus, which is considered to be premalignant. METHODS: Of 69 patients born between 1971 and 1978, all having undergone a primary anastomosis, 24 had died, five of them because of aspiration. Of the 45 survivors, 39 could be traced; they all completed a questionnaire inquiring after symptoms related to the esophagus. Of these patients, 34 underwent an additional esophagogastrocopy. RESULTS: Only nine of the 39 patients had no symptoms at all; 30 had mild to severe dysphagia symptoms, and 13 had mild to severe reflux symptoms. Esophagogastrocopy in 34 patients revealed that the anastomosis was still recognizable in all cases, but stenoses were not found. Six patients showed a small hiatal hernia, and one a large one. The incidences of reflux symptoms (13/39, p < 0.01), reflux esophagitis (9/34, p < 0.01) and Barrett's esophagus (2/34, p < 0.001) were significantly higher than in the normal population. CONCLUSIONS: This group seems to be at risk for developing Barrett's esophagus. As this is the first follow-up study of a consecutive group of adult esophageal atresia patients, we think it is advisable to perform an esophagogastroscopy in all patients at adulthood until more long term follow-up data are available.     

Erosive Esophagitis and Barrett's Esophagus in Taiwan (A Higher Frequency than Expected)

In contrast to Western countries, erosiveesophagitis has been considered less common, Barrett'sesophagus presumed less frequent, and hiatal herniaextremely uncommon in the Orient. However, accelerated modernization and adoption of Western customshave resulted in marked life-style changes in manyAsians in the Orient that may potentially affect thefrequency of erosive esophagitis and Barrett's esophagus in this population. Our aim was to determinethe current frequency of erosive esophagitis, Barrett'sesophagus, and other gastroesophageal reflux diseasecomplications in self-referred Chinese patients undergoing upper gastrointestinal endoscopy inTaipei, Taiwan. Between July 1991 and June 1992, 464consecutive patients underwent endoscopy for a varietyof upper gastrointestinal symptoms at a major medical center. The presence of erosive esophagitis,strictures, Barrett's esophagus, and hiatal hernia wasrecorded. The extent of mucosal injury was determined byusing the Savary-Miller grading system. Sixty-six (14.5%) patients were found to have erosiveesophagitis, 9 (2%), Barrett's esophagus, and 32 (7%)hiatal hernias. Erosive esophagitis showed amale-to-female preponderance of 3.1:1. Disease severityincreased with age and peaked during the sixth andseventh decades. We concluded that in contrast toprevious experience, the Chinese population in Taiwanappears to have a higher frequency of erosiveesophagitis, Barrett's esophagus, and hiatal hernia.Increased fat consumption, aging, and other possiblefactors are suggested as possible mechanisms.     

Correlation of gastroesophageal reflux disease symptoms characteristics with long-segment Barrett''s esophagus

Thus far, there has been a paucity of studies that have assessed the value of the different gastroesophageal reflux disease (GERD) symptom characteristics in identifying patients with long-segment Barrett's esophagus versus those with short-segment Barrett's esophagus. To determine if any of the symptom characteristics of GERD correlates with long-segment Barrett's esophagus versus short-segment Barrett's esophagus. Patients seen in our Barrett's clinic were prospectively approached and recruited into the study. All patients underwent an endoscopy, validated GERD symptoms questionnaire and a personal interview. Of the 88 Barrett's esophagus patients enrolled into the study, 47 had short-segment Barrett's esophagus and 41 long-segment Barrett's esophagus. Patients with short-segment Barrett's esophagus reported significantly more daily heartburn symptoms (84.1%) than patients with long-segment Barrett's esophagus (63.2%, P = 0.02). There was a significant difference in reports of severe to very severe dysphagia in patients with long-segment Barrett's esophagus versus those with short-segment Barrett's esophagus (76.9%vs. 38.1%, P = 0.02). Longer duration in years of chest pain was the only symptom characteristic of gastroesophageal reflux disease associated with longer lengths of Barrett's mucosa. Reports of severe or very severe dysphagia were more common in long-segment Barrett's esophagus patients. Only longer duration of chest pain was correlated with longer lengths of Barrett's esophagus.