Barrett's esophagus and Helicobacter pylori

Lifestyles of Japanese, including eating habits, have been similar to those in Western countries, which might be related to an increase in gastroesophageal reflux disease (GERD) in Japan. Barrett's esophagus is generally accepted as a complication of chronic and severe GERD. Helicobacter pylori (H. pylori) is a pathogen that is associated with atrophic gastritis, peptic ulcer disease, gastric adenocarcinoma, mucosa-associated lymphoid tissue lymphoma, and so on. The relationship between H. pylori and GERD+ Barrett's esophagus is controversial. H. pylori eradication therapy may increase the risk for the development of GERD, which may lead to increase a risk factor of Barrett's esophagus and esophageal adenocarcinoma. This review gives the outline regarding GERD and the relation between Barrett's esophagus and H. pylori infection.     

Radiologic diagnosis of Barrett's esophagus: Critical analysis of 65 cases

A recent increase in the number of Barrett's esophagis being diagnosed is probably directly related to a proportional increase in endoscopic biopsies of the esophagus and awareness of premalignant potential of Barrett's mucosa. While the endoscopist can detect Barrett's mucosa with fair degree of accuracy, the radiologic diagnosis of Barrett's esophagus still remains a diagnostic challenge despite several well established radiologic features. We reviewed 65 patients with pathologically proven Barrett's esophagus and found a wide spectrum of radiologic features. These include hiatus hernia in 49, gastroesophageal reflux in 38, strictures in 32, esophagitis in 20, and characteristic Barrett's ulcer in 12. In addition ascending or migrating strictures were found in 10, mucosal pattern simulating areae gastricae in 5, cricopharyngeal dysfunction in 4, and fixed spiral folds in 3 patients. This constellation of radiologic features, some of which have not been previously emphasized, should further assist radiologists in suggesting the diagnosis of Barrett's esophagus.     

Campylobacter pylori and Barrett's esophagus

Occurrence of C. pylori infection of mucosa outside of the stomach might provide an ideal opportunity to examine C. pylori-mucosal interactions apart from the effects of acid and pepsin. Techniques previously used to examine Barrett's epithelium (for example, special mucin stains or scanning and transmission electron microscopy) might be particularly useful for exploration of new associations and formulation of new hypotheses. Whether C. pylori has a role in development of Barrett's ulcer or adenocarcinoma as a complication of Barrett's esophagus remains unanswered. Most of the current data about C. pylori are primarily observational; further studies are needed for clarification of important microbegut interactions.     

Barrett's esophagus occurring as a complication of scleroderma

Two patients had both scleroderma and a columnar epithelium-lined lower esophagus (Barrett esophagus). Features of Barrett's esophagus included high esophageal strictures in both patients and ulcer craters in the columnar area of one. Biopsy confirmed columnar epithelium in the lower esophagus of each patient. In these patients, the Barrett esophagus probably was a complication of scleroderma and resulted from long-standing gastroesophageal reflux.     

Helicobacter pylori infection and eradication

H. pylori infection is associated with various gastroduodenal diseases such as gastritis, peptic ulcer, gastric cancer, gastric MALT lymphoma. H. pylori infection is suggested that it plays a role as protective factor not promoting factor for reflux esophagitis and GERD. Epidemiological studies showed lower prevalence of H. pylori infection in reflux esophagitis and Barrett's esophagus comparing the control. Increased occurrence of reflux esophagitis after curing of H. pylori infection was reported. However, the relationship between H. pylori infection and reflux esophagitis has not been actually made clear. Also the mechanism of reflux esophagitis occurrence after H. pylori eradication is not obscure.     

Differential Diagnosis of Subacute Febrile Arthritis

The importance of the treatment of duodenal ulcer is apparent from the fact that 10 percent of adult males have or have had an ulcer. Treatment consisting of an hourly ulcer schedule, with food or milk on the even hours and antacids on the odd hours, is outlined. Encouraging results have been obtained with a new anticholinergic drug (BANTHINE®). The use of banthine or other new anticholinergic drugs as an adjunct to the routine ulcer treatment outlined is recommended. When surgery is necessary for duodenal ulcer (as in 10 to 15 per cent of our patients), we believe vagotomy with gastroenterostomy is usually the operation of choice.     

Diagnosis of gastric ulcer in the elderly

It is well known that gastric ulcers are most often found at anglus and upper corpus in the elderly. The number of gastric ulcer found at upper corpus hold half of all cases in the elderly patients with bleeding ulcer. Sixty percent of the elderly patients with bleeding ulcer took NSAIDs including low-dose aspirin in authors' hospital. Now it is easy to treat and cure bleeding ulcers due to development of endoscopic hemostasis and antiulcer drugs such as proton pump inhibitor(PPI). However, the elderly patients sometimes result in fatal outcome on bleeding from gastric ulcer. Therefore, it is important to prevent ulcer complications by PPI for the high-risk group such as elderly patients taking NSAIDs.     

Barrett's esophagus in scleroderma: Increased prevalence and radiographic findings

Ten of 27 patients (37%) with scleroderma who underwent endoscopy at our hospital between 1980 and 1984 for symptoms of reflux esophagitis had biopsy-proven Barrett's esophagus. Two of those 10 patients had esophageal adenocarcinomas. In a blinded review of esophagrams (all but 2 using double-contrast technique) from 16 of the 27 patients, only 1 patient was thought to be at high risk for Barrett's esophagus due to a high esophageal stricture with an adjacent reticular pattern of the mucosa. The latter patient had biopsy-proven Barrett's mucosa. Eight patients were thought to be at moderate risk for Barrett's esophagus due to reflux esophagitis and/or distal strictures in 6 and polypoid intraluminal masses in 2. Three of the 6 patients with esophagitis and/or strictures had Barrett's esophagus, and both patients with masses had adenocarcinomas arising in Barrett's mucosa. Finally, 7 patients who had no esophagitis or strictures were thought to be at low risk for Barrett's esophagus. None of those 7 had histologic evidence of Barrett's mucosa. Thus, the major value of double-contrast esophagography is its ability to classify patients into high-, moderate-, and low-risk for Barrett's esophagus to determine the relative need for endoscopy and biopsy in these patients.     

Peptic ulcer disease.

Peptic ulcer disease affects between 5 percent and 10 percent of Americans during their lifetime. There are a variety of predisposing factors, including nonsteroidal anti-inflammatory drug (NSAID) use, Helicobacter pylori infection, tobacco use and, possibly, certain dietary practices. While H2-receptor antagonists remain the mainstay of therapy, the selection of an antiulcer drug should be individualized. Famotidine is preferred in persons who use alcohol, sucralfate may be preferred for maintenance therapy in smokers and omeprazole is useful in hypersecretors of acid and in patients with resistant ulcers. Antacids remain an effective treatment for uncomplicated duodenal ulcer in motivated patients. Eradication of H. pylori using a bismuth preparation plus one or two antibiotic agents should be considered in patients who have frequent recurrences and evidence of infection. Finally, risk factors such as tobacco or NSAID use should be modified whenever possible to reduce the risk of ulcer recurrence.     

Barrett食管患者幽门螺杆菌感染率的Meta分析

目的分析Barrett食管患者幽门螺杆菌感染率及caga阳性的幽门螺杆菌感染率，并与内镜检查正常者和胃食管反流病患者比较，探讨幽门螺杆菌（Helicobacter pylori，Hp）感染与Barrett食管的关系。方法计算机检索MEDLINE和EMbase数据库至2008年2月，纳入比较Barrett食管患者和内镜检查正常者及胃食管反流病（gastroesophageal reflux disease，GERD）患者Hp感染率的病例对照研究或队列研究。统计分析采用RevMan4．2．8，计算比值比OR（95％CI）。结果共纳入19篇文献，包括16篇病例对照研究和3篇队列研究。病例对照研究分析结果显示，Barrett食管患者比内镜检查正常者Hp感染率低[OR0．56，95％CI（0．40，0．79）]，与GERD患者相比差异无统计学意义[OR0．86，95％CI（0．74，1．00）]。队列研究的分析结果显示，Barrett食管患者与内镜检查正常者及GERD患者相比Hp感染率差异无统计学意义[OR1．12，95％CI（0．77，1．61）；OR1．10，95％CI（0．32，3．83）]。cagA阳性Hp感染率较内镜正常者及GERD患者低[OR0．30，95％CI（0．12，0．74）；OR0．55，95％CI（0．33，0．94）]。病例对照研究长节段较短节段Barrett食管Hp感染率低[OR0．32，95％CI（0．16，0．66）]。而队列研究结果显示，长节段较短节段Barrett食管患者Hp感染率差异无统计学意义[OR0．66，95％CI（0．29，1．48）]。结论Barrett食管患者和GERD患者Hp感染率无差别，Barrett食管患者Hp感染率，特别是cagA阳性Hp菌株感染率较内镜检查正常者明显减少。     

Epidemiology of Barrett's esophagus--comparison of Japan and the West

We compared the epidemiology of Barrett's esophagus in Japan and the West. Japan GERD Society Study Committee conducted the epidemiological survey in 2,595 patients who underwent endoscopy the first time, confirming that Barrett's mucosa was observed in 536 patients (20.8%) out of 2,577. But Barrett's esophagus (>3 cm of columnar lined epithelium) was detected only 5 (0.2%). The prevalence of typical Barrett's esophagus was markedly low in Japanese compared with Westerners. In Western, the incidence of Barrett's esophagus has increased markedly since the 1970s. It is estimated that Barrett's esophagus is found in approximately 6-12% of patients undergoing endoscopy for symptoms of GERD and in 1% or less of unselected patient populations undergoing endoscopy.     

Percent change in wound area of diabetic foot ulcers over a 4-week period is a robust predictor of complete healing in a 12-week prospective trial

OBJECTIVE: To assess the ability of the 4-week healing rate to predict complete healing over a 12-week period in a large prospective multicenter trial of diabetic patients with foot ulceration. RESEARCH DESIGN AND METHODS: We examined the change in ulcer area over a 4-week period as a predictor of wound healing within 12 weeks in patients who were seen weekly in a prospective, randomized controlled trial. RESULTS: Wound area measurements at baseline and after 4 weeks were performed in 203 patients. The midpoint between the percentage area reduction from baseline at 4 weeks in patients healed versus those not healed at 12 weeks was found to be 53%. Subjects with a reduction in ulcer area greater than the 4-week median had a 12-week healing rate of 58%, whereas those with reduction in ulcer area less than the 4-week median had a healing rate of only 9% (P < 0.01). The absolute change in ulcer area at 4 weeks was significantly greater in healers versus nonhealers (1.5 vs. 0.8 cm(2), P < 0.02). The percent change in wound area at 4 weeks in those who healed was 82% (95% CI 70-94), whereas in those who failed to heal, the percent change in wound area was 25% (15-35; P < 0.001). CONCLUSIONS: The percent change in foot ulcer area after 4 weeks of observation is a robust predictor of healing at 12 weeks. This simple tool may serve as a pivotal clinical decision point in the care of diabetic foot ulcers for early identification of patients who may not respond to standard care and may need additional treatment.     

Endoscopic diagnosis of Barrett's esophagus

In Japan Barrett's mucosa is defined as columnar lined esophagus (CLE). The prevalence of Barrett's esophagus and Barrett's adenocarcinoma is very low. But in Western countries Barrett's mucosa is defined as CLE with intestinal metaplasia, and many cases of Barrett's esophagus and Barrett's adenocarcinoma are reported. The definite endoscopic diagnosis of Barrett's mucosa cannot be so easy. We investigated the positional relationship between the esophageal hiatus, squamo-columnar junction, and longitudinal vessels in persons who underwent esophagogastroduodenoscopy. Subepithelial longitudinal vessels were found at the lower esophagus in all cases. In no cases were the longitudinal vessels observed under the gastric mucosa beyond the esophageal hiatus. It is peculiar to the esophagus to be able to observe subepithelial longitudinal vessels in the vicinity of the esophago-gastric junction. When longitudinal vessels are found only under the columnar epithelium at the oral side over the esophageal hiatus from the stomach, this indicates Barrett's epithelium. Thus the definite diagnosis of Barrett's epithelium can be made by endoscopy.     

Clinical efficacy of combined anti-Helicobacter treatment of patients with duodenal ulcer

84 patients with duodenal ulcer and positive by Helicobacter pylori (HP) were divided into two groups. Group 1 consisted of 42 patients who received omeprasol, metranidasol and clarithromycin. Group 2 of 42 patients received rovamycin instead of clarythromycin. The results of the study show that anti-HP regimen with rovamycin is superior to clarythromycin by main criteria (percent of healed ulcers, HP eradication, time to remission, recurrence rate, side effects rate). Thus, three-component therapy of patients with recurrent duodenal ulcer maintains intragastric acidity optimal for fast healing of ulcer defect.     

Abnormal expression of growth regulatory factors in Barrett's oesophagus.

1. In order to assess potential abnormalities in the control of mucosal proliferation, 30 patients with Barrett's oesophagus were studied in order to evaluate the presence and distribution of epidermal growth factor, transforming growth factor-alpha and epidermal growth factor receptor to determine the Ki-67 labelling index in the affected oesophageal mucosa. Serial sections were analysed immunohistochemically. Ten of the patients had adenocarcinoma in the Barrett's mucosa and the other 20 had differing histological types of Barrett's mucosa (10, intestinal-type; 10, fundic- or cardiac-type). 2. The expression of transforming growth factor-alpha, epidermal growth factor and epidermal growth factor receptor was increased and the Ki-67 labelling index was higher in Barrett's mucosa compared with normal gastric mucosa. The 'intestinal-type' of Barrett's mucosa had the greatest expression of transforming growth factor-alpha, epidermal growth factor receptor and the highest Ki-67 labelling index compared with the other types of Barrett's metaplasia. Five cases of 'intestinal-type' Barrett's metaplasia had especially high Ki-67 labelling indices and these patients over-expressed both transforming growth factor-alpha and epidermal growth factor receptor. The patients with adenocarcinomas in the Barrett's mucosa also over-expressed transforming growth factor-alpha and epidermal growth factor receptor, but not epidermal growth factor, compared with normal gastric mucosa. 3. In conclusion, both normal gastric mucosa and Barrett's mucosa have potential autocrine growth regulatory mechanisms, but Barrett's mucosa has increased expression of both of the measured ligands and of the epidermal growth factor receptor.     

Progression and extending speed of Barrett's esophagus

Barrett's esophagus is one of the terminal manifestations of reflux esophagitis. Although the typical Barrett's esophagus is very rare in Japan, the prevalence rate of short-segment Barrett's esophagus is extremely higher comparing with in western countries. The discrepancy may be caused by the differences of criteria of short-segment Barrett's esophagus. Observation of Barrett's mucosa in residual esophagus after esophagectomy is a useful method of considering the extension of Barrett's esophagus. Short-segment Barrett's esophagus accompanied by gastro-esophageal reflux may show a rapid extension under some adequate conditions. Large volume prospective studies are needed to clarify the extension speed of Barrett's esophagus.     

Endoscopic ablation of Barrett's neoplasia with a new focal radiofrequency device: initial experience with the Halo60

Radiofrequency ablation (RFA) is an accepted treatment for the eradication of dysplastic Barrett's esophagus (DBE) and residual Barrett's esophagus after endoscopic resection of intramucosal adenocarcinoma. Circumferential balloon-based and focal catheter-based RFA devices are currently used (the Halo360 and Halo90). However, a new smaller focal ablation device (the Halo60) has been developed, which may be of benefit in patients with short tongues of Barrett's neoplasia, small residual islands, difficult anatomy, or strictures. We report the first use of this device in 17 patients with either DBE or residual Barrett's esophagus after endoscopic resection of intramucosal adenocarcinoma.     

Hereditary spherocytosis with leg ulcers healing after splenectomy

Hereditary spherocytosis (HS) is a familial hemolytic disorder with marked heterogeneity. A refractory chronic leg ulcer is an uncommon complication of HS, reported in fewer than two percent of patients. We present the case of a 28-year-old man who was suffering from a leg ulcer and was unresponsive to treatment of two years' duration with various conservative modalities. He had been suffering from repeated attacks of jaundice, pallor, and splenomegaly since he was 10 years old. Upon admission, physical and laboratory findings revealed moderate HS. However, complete clearance of the leg ulcer was not achieved until two months after a splenectomy.     

Chromoendoscopic diagnosis of Barrett's esophagus

Some kinds of chromoendoscopy have been reported to survey the cases with Barrett's esophagus more effectively, since random biopsy as a gold standard is not an ideal method from the viewpoint of safety, labor or cost effectiveness. Methylene blue (MB) chromoendoscopy has been reported that a targeted biopsy is possible to limit because MB only stains non-dysplastic Barrett's mucosa but not dysplastic one. However, many of supplementary studies have not agreed this recommendation. Crystal violet (CV) chromoendoscopy clearly stains Barrett's mucosa and makes a detailed observation of pit pattern possible. The availability of this method is required a further mass survey although CV chromoendoscopy has been reported to be effective in Barrett's screening. Other chromoendoscopic methods using indigo carmine or fluorescence dye also have been reported to be effective for discovering a dysplastic lesion by some investigator, but the efficacy has not been sufficiently evidenced. Conclusively, chromoendoscopic diagnosis of Barrett's esophagus has not yet got a consensus in the availability for Barrett's surveillance at present in Barrett's Esophagus Chicago Workshop 2003 of AGA.     

Present state and measures of Barrett's cancer in Japan

Barrett's adenocarcinoma is common esophageal cancer in western countries but very rare in Japan. We reviewed 206 cases of Barrett's cancer in Japanese literature that issued from 2000 to 2004. 80% of them were superficial cancer. There was no mucosal Barrett's cancer with lymph nodes metastasis, therefore EMR (endoscopic mucosal resection) method is an appropriate way for mucosal cancer. Barrett's cancer with submucosal invasion occur lymph nodes metastasis, so surgical operation should be applied for deeper invasion to submucosal cancer.