Primary adenocarcinoma of the cervical esophagus arising from heterotopic gastric mucosa

Received: February 18, 2000 / Accepted: November 17, 2000     

pH profile of esophagus in patients with inlet patch of heterotopic gastric mucosa after tetragastrin stimulation

In a series of 1771 endoscopic examinations from 1988 to 1990, we observed 62 cases (3.3%) of inlet patch of heterotopic gastric mucosa (IPHGM) in the upper esophagus. Ten of the IPHGM patients complained of throat discomfort or globus sensation, and these symptoms were relieved by histamine H₂-antagonists, suggesting that these symptoms could be caused by acid secretion from IPHGM. Acidity under tetragastrin stimulation was measured in the esophagus and compared with the pool of gastric juice and saliva under direct vision by a newly devised endoscopic method. Congo red staining was also carried out after pH measurement. Significant pH reduction at IPHGM was observed in three cases, and black coloration with Congo red staining in the IPHGM was observed in four cases. These findings suggest that IPHGM is a mucosal change with latent acid secretion.     

Esophageal motility and gastric acid secretion in patients with Barrett's esophagus

Patients with Barrett's esophagus (BE) usually have low resting lower esophageal sphincter (LES) pressure, and also have impaired esophageal body motility, with low amplitude and failed peristaltic contractions on swallowing being common. These motor abnormalities contribute to excessive esophageal acid exposure in patients with BE. However, gastric acid secretion is not different between patients with BE and reflux esophagitis.     

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     

食管上段胃黏膜异位症

食管上段胃黏膜异位症(heterotopic gastric mucosa in upper esophagus,HGMUE)是胚胎发育时期鳞状上皮不完全取代柱状上皮形成的先天性残余病变．发病率0．1％-10％,患者多无临床症状,但也可以出现胸骨后烧灼感、吞咽困难或疼痛、咽部不适等症状,可导致溃疡、穿孔、瘘管、狭窄等并发症．诊断依赖内镜和活检．处理包括随访、对症、内镜下黏膜切除、局段食管切除等．我们就该病变相关研究资料作一全面综述．     

Prevalence of cervical esophageal heterotopic gastric mucosa

Abstract

Objective. Capsule endoscopy (CE) is a novel investigation for the diagnosis of small-bowel disease but its interpretation is highly subjective. We studied the inter-observer agreement and accuracy of the interpretation of CE findings based on capsule endoscopy structured terminology (CEST). Material and methods. Fifty-six CE video clips were collected from eight university hospitals in South Korea and were independently reviewed by 13 gastroenterology experts and 10 trainees. All investigators recorded their findings based on CEST. To determine the accuracy of individual viewers, we defined the ‘gold standard’ as a joint review by four experts. Results. The 56 CE video clips included five normal cases, 19 cases of protruding lesions, 21 cases of depressed lesions, three cases of flat lesions, one case of abnormal mucosa, six cases with blood in the lumen, and one case of stenotic lumen. The overall mean accuracies for the experts and trainees were 74.3% ± 22.6% and 61.7% ± 25.4%, respectively. The overall accuracy for the trainee group was significantly lower than that for the expert group (P Conclusions. Our results showed that there was substantial agreement between experts and moderate agreement between trainees. In order to achieve higher accuracies and better inter-observer agreement, we need not only more experience with CE but also consensus regarding CEST terminology.     

内镜检查对食管胃黏膜异位的诊断意义

目的:分析食管胃黏膜异位症(HGM)内镜下表现特征及其病理学特点, 探讨幽门螺杆菌( H pylori)与HGM的关系.方法:2007-01/2008-12我院门诊HGM患者27例, 均经病理组织学证实, 行电子胃镜检查, 进镜后观察食管黏膜, 行黏膜活检病理检查, 以及快速尿素酶检验, 阳性者诊为H pylori感染.结果:内镜检查发现异位灶共34处, 其中单病灶占77.8%, 多沿长轴纵行分布; 双病灶占18.5%, 多呈对吻性; 3个病灶占3.7%. 病变呈椭圆形或圆形, 橘红色或深红色黏膜区, 与周围的灰白色正常食管黏膜分界清楚, 直径为0.5-2.5 cm. 1例伴有0.75 cm大小圆形浅溃疡.病理检查显示可见胃柱状上皮, 含有壁细胞和主细胞, 其中51.9%见炎性细胞浸润. 37%H pylori检测呈阳性, 在HGM伴有慢性炎症及肠上皮化生者中35.3% H pylori呈阳性.结论:HGM存在H pylori感染, 但感染与病变程度无明确相关性, 内镜检查技术的完善及活检的充分和准确, 对于HGM具有重要的确诊意义.     

Adenocarcinoma arising from heterotopic gastric mucosa in the cervical esophagus and upper thoracic esophagus: two case reports and literature review

Primary adenocarcinoma arising from heterotopic gastric mucosa (HGM) is rare and the clinicopathological characteristics are not well known. We present two cases of esophageal adenocarcinoma arising from HGM with a review of a case series. Case 1 was a 78-year-old woman who underwent a periodic medical examination without complaining of any symptoms. Preoperative evaluation suggested esophageal adenocarcinoma arising from the HGM. The patient was treated with endoscopic submucosal dissection. Definitive pathological diagnosis confirmed adenocarcinoma arising from the HGM. Case 2 was a 70-year-old man who underwent a medical examination after complaining of dysphagia. Preoperative diagnosis suggested esophageal adenocarcinoma; however, its origin was unclear. The patient was treated with surgical resection. Definitive pathological diagnosis revealed adenocarcinoma arising from the HGM. In this article, the authors report the clinicopathological features of esophageal adenocarcinoma arising from HGM that were collected from a literature review and our cases.     

The inlet patch: heterotopic gastric mucosa in the upper esophagus

Careful endoscopic survey of the upper esophagus indicates that a visually recognizable patch of gastric mucosa is grossly visible much more commonly than is generally recognized. Sixteen instances were found in 420 sequential endoscopies, an incidence of 3.8%. The gastric mucosal rest presented as a velvety red patch with a distinct border, varying from a few millimeters in diameter to complete encirclement of the esophagus, was occasionally paired, and was found either at or just below the upper esophageal sphincter. In all instances except one the patch consisted of gastric-type mucosa containing both parietal and chief cells; in the single exception, it consisted of gastric-type mucous glands without parietal cells. Although larger patches can be shown to function under stimulation (they produce a local drop in pH with pentagastrin stimulation), there are usually no apparent associated clinical symptoms.     

食管上段胃黏膜异位症的临床、内镜及组织学特点

目的　探讨食管上段胃黏膜异位症（heterotopic gastric mucosa in upper esophagus,HGMUE）的临床、内镜和组织学特点。方法　2017年1—12月,在华中科技大学同济医学院附属协和医院内镜中心行常规胃镜检查,胃镜下发现食管上段胃黏膜异位斑的177例患者纳入研究,根据胃食管反流症状评分量表（GERD?Q）评分结果分成2组,即HGMUE组（GERD?Q<8分,n=101）和HGMUE合并胃食管反流病组（HGMUE+GERD组,GERD?Q≥8分,n=76）,对临床、内镜和病理资料进行汇总和分析。结果　177例HGMUE患者中,男111例（62.71%）、女66例（37.29%）,合并GERD 76例（42.94%）、未合并GERD 101例（57.06%）,持续清嗓的发生率最高［54.24%（96/177）］,其次为咽部异物感［48.59%（86/177）］和烧心、胸痛、消化不良、胃酸反流［48.59%（86/177）］。HGMUE组中,持续清嗓的发生率最高［42.57%（43/101）］,其次为咽部异物感［33.66%（34/101）］和烧心、胸痛、消化不良、胃酸反流［27.72%（28/101）］;HGMUE+GERD组中,烧心、胸痛、消化不良、胃酸反流的发生率最高［76.32%（58/76）］,其次为持续清嗓［69.74%（53/76）］和咽部异物感［68.42%（52/76）］。共检出177处食管上段胃黏膜异位斑,胃镜下通常表现为橘红色圆形、椭圆形或长条形的岛状病灶,大多数较平坦、少数稍凸出周边平面,单发132例（74.58%）、2处病灶38例（21.47%）、3处及3处以上病灶7例（3.95%）,小病灶（最大直径<0.5 cm）37处（20.90%）、中等大小病灶（最大直径在0.5～1.0 cm）74处（41.81%）、较大病灶（最大直径>1.0 cm）66处（37.29%）。有30例［16.95%（30/177）］接受了活检组织学检查,胃底腺为主型15例［50.00%（15/30）］、幽门腺为主型8例［26.67%（8/30）］、混合型6例［20.00%（6/30）］、剩余1例［3.33%（1/30）］为鳞状上皮,20例［66.67%（20/30）］免疫组化H+/K+?ATP酶阳性、10例［33.33%（10/30）］免疫组化H+/K+-ATP酶阴性。结论　HGMUE多见于男性患者,可合并亦可不合并GERD,其中合并GERD者更易发生咽喉反流。内镜下胃黏膜异位斑多表现为橘红色圆形、椭圆形或长条形的岛状病灶,大多数较平坦,以单发为主,多为中等及较大病灶。组织学分型以胃底腺为主型,免疫组化H+/K+?ATP酶阳性多见,推测酸分泌可能是导致咽喉症状的重要因素。分 析 。 结 果 177 例 HGMUE 患 者 中 ,男 111 例（62.71%）、女 66 例（37.29%）,合 并 GERD 76 例 （42.94%）、未合并 GERD 101 例（57.06%）,持续嗓嗓的发生率最高［54.24%（96/177）］,其次为咽部异物感［48.59%（86/177）］和烧心、胸痛、消化不良、胃酸反流［48.59%（86/177）］。HGMUE 组中,持续清嗓的发生率最高［42.57%（43/101）］,其次为咽部异物感［33.66%（34/101）］和烧心、胸痛、消化不良、胃酸反流［27.72%（28/101）］HGMUE+GERD 组中,烧心、胸痛、消化不良、胃酸反流的发生率最高［76.32%（58/76）］,其次为持续清嗓［69.74%（53/76）］和咽部异物感［68.42%（52/76）］。共检出177处食管上段胃黏膜异位斑,胃镜下通常表现为橘红色圆形、椭圆形或长条形的岛状病灶,大多数较平坦、少数稍凸出周边平面,单发 132 例（74.58%）、2 处病灶 38 例（21.47%）、3 处及 3 处以上病灶 7 例 （3.95%）,小病灶（最大直径<0.5 cm）37 处（20.90%）、中等大小病灶（最大直径在 0.5～1.0 cm）74 处（41.81%）、较大病灶（最大直径>1.0 cm）66 处（37.29%）。有 30 例［16.95%（30/177）］接受了活检组织学检查,胃底腺为主型 15 例［50.00%（15/30）］、幽门腺为主型 8 例［26.67%（8/30）］、混合型 6 例 ［20.00%（6/30）］、剩余 1例［3.33%（1/30）］为鳞状上皮,20例［66.67%（20/30）］免疫组化 H+/K+-ATP 酶阳性、10例［33.33%（10/30）］免疫组化H+/K+-ATP酶阴性。结论 HGMUE多见于男性患者,可合并亦可不合并GERD,其中合并GERD者更易发生咽喉反流。内镜下胃黏膜异位斑多表现为橘红色圆形、椭圆形或长条形的岛状病灶,大多数较平坦,以单发为主,多为中等及较大病灶。组织学分型多为胃底腺为主型,免疫组化H+/K+-ATP酶阳性多见,推测酸分泌可能是导致咽喉症状的重要因素。 【关键词】 胃食管反流; 食管上段胃黏膜异位症; 咽喉反流; 酸分泌     

Correlation of Lower Esophageal Mucosal Ring and 24-h pH Monitoring of the Esophagus

Objective : To study the relationship of LEMR and gastroesophageal reflux. The pathogenesis of the lower esophageal mucosal ring (LEMR) is not known. The most likely theory is that the ring results from reflux esophagitis as part of the morphological spectrum of peptic stricture. Methods : We correlated barium esophagrams and 24-h pH monitoring (pHM) in 343 patients (173 women, 170 men; mean age 52 yr). Patients were categorized into three groups by radiographic findings: 1) normal esophagus (n = 121), 2) hiatal hernia (HH) only (n = 174), and 3) LEMR (n = 48). Abnormal pHM was defined as a total percentage of the esophageal acid exposure time of 6% or more; abnormal pHM was also analyzed relative to patient position (supine vs. upright). Results : Findings showed that 21 (17%) of 121 normal patients bad abnormal pHM compared with 58 (33%) of 174 patients with HH and 15 (31%) of 48 patients with LEMR. Normal patients had a significantly lower frequency of abnormal pHM (p < 0.01) vs. the other two groups; however, no significant difference in results of pHM was found in the groups with HH and LEMR. No significant relationships of abnormal supine versus upright pHM was observed comparing the three groups. Conclusions : 1) Most patients in this study bad normal pHM, regardless of the anatomic status of the esophagogastric region; 2) patients with HH and LEMR had a higher frequency of abnormal pHM, although the two groups were not significantly different; and 3) an etiological relationship of LEMR and gastroesophageal reflux was not supported, other than its association with HH.     

Endoscopic diagnosis of cervical esophageal heterotopic gastric mucosa with conventional and narrow-band images

AIM:To compare the diagnostic yield of heterotopic gastric mucosa(HGM)in the cervical esophagus with conventional imaging(CI)and narrow-band imaging(NBI).METHODS:A prospective study with a total of 760patients receiving a CI examination(mean age 51.6years;47.8%male)and 760 patients undergoing NBI examination(mean age 51.2 years;45.9%male).The size of HGM was classified as small(1-5 mm),medium(6-10 mm),or large(>1 cm).A standardized questionnaire was used to obtain demographic characteristics,social habits,and symptoms likely to be related to cervical esophageal HGM,including throat symptoms(globus sensation,hoarseness,sore throat,and cough)and upper esophageal symptoms(dysphagia and odynophagia)at least 3 mo in duration.The clinicopathological classification of cervical esophageal HGM was performed using the proposal by von Rahden et al.RESULTS:Cervical esophageal HGM was found in 36of 760(4.7%)and 63 of 760(8.3%)patients in the CI and NBI groups,respectively(P=0.007).The NBI mode discovered significantly more small-sized HGM than CI(55%vs 17%;P<0.0001).For the 99 patients with cervical esophageal HGM,biopsies were performed in 56 patients;37(66%)had fundic-type gastric mucosa,and 19 had antral-type mucosa.For the clinicopathological classification,77 patients(78%)were classified as HGMⅠ(asymptomatic carriers);21 as HGMⅡ(symptomatic without morphologic changes);and one as HGMⅢ(symptomatic with morphologic change).No intraepithelial neoplasia or adenocarcinoma was found.CONCLUSION:NBI endoscopy detects more cervical esophageal HGM than CI does.Fundic-type gastric mucosa constitutes the most common histology.One-fifth of patients have throat or dysphagic symptoms.     

Transcutaneous cervical esophagus ultrasound in adults： Relation with ambulatory 24-h pH-monitoring and esophageal manometry

AIM To determine the gastroesophageal refluxate in the cervical esophagus (CE) and measure transcutaneous cervical esophageal ultrasound (TCEUS) findings [anterior wall thickness (WT) of CE, esophageal luminal diameter (ELD), esophageal diameter (ED)]; to compare TCEUS findings in the patient subgroups divided according to 24-h esophageal pH monitoring and manometry; and to investigate possible cut-off values according to the TCEUS findings as a predictor of gastroesophageal reflux (GER).METHODS In 45/500 patients, refluxate was visualized in TCEUS. 38/45 patients underwent esophagogastroduo denoscopy (EGD), 24-h pH monitoring and manometry.RESULTS The 38 patients were grouped according to 24-h pH monitoring as follows Group A GER-positive (n = 20) [Includes Group B isolated proximal reflux (PR) (n = 6), Group C isolated distal reflux (DR) (n = 6),and Group D both PR/DR (n = 8)]; Group E no reflux (n = 13); and Group F hypersensitive esophagus (HSE) (n= 5). Groups B D indicated total PR patients (n = 14),Groups E F reflux-negatives with HSE (n = 18), and Groups A F reflux-positives with HSE (n = 25). When the 38 patients were grouped according to manometry findings, 24 had normal esophageal manometry; 7 had hypotensive and 2 had hypertensive lower esophageal sphincter (LES); and 5 had ineffective esophageal motility disorder (IEM). The ELD measurement was greater in group A F than group E (P = 0.023, 5.0 ± 1.3 vs 3.9 ± 1.4 mm). In 27/38 patients, there was at least one pathologic acid reflux and/or pathologic manometry finding. The cut-off value for ELD of 4.83 mm had 79% sensitivity and 61% specificity in predicting the PR between Groups B D and E (AUC = 0.775, P = 0.015).CONCLUSION Visualizing refluxate in TCEUS was useful as a pre-diagnostic tool for estimating GER or manometric pathology in 71.1% of adults in our study,but it was not diagnostic for CE WT.