Extension of squamous epithelium into the proximal stomach: a newly recognized mucosal abnormality

BACKGROUND AND STUDY AIMS: The presence of squamous epithelium in the stomach has been rarely noted in the past with only sporadic case reports of squamous cell carcinoma of the stomach and a variety of other pathological processes. We report the documentation, over a period of 9 months, of squamous epithelium extending beyond the esophagogastric junction and into the proximal stomach in 16 patients who underwent upper endoscopy. PATIENTS AND METHODS: This newly recognized mucosal abnormality was systematically identified by both antegrade and retrograde views of the esophagogastric junction during routine upper endoscopy. Other associated mucosal abnormalities were also evaluated (Barrett's esophagus, erosive esophagitis, etc.). Biopsies were obtained from the distal esophagus, cardia, antrum and the squamous extension. Additionally, all patients underwent a detailed interview. RESULTS: Of the patients, 14 were Caucasian and two Hispanic; all were males, with a mean age 61.2+/-4.2. Indications for upper endoscopy included dysphagia, Barrett's esophagus surveillance, failure of antireflux treatment and anemia. Heartburn was reported by 12 patients (75%). None of the patients reported a history of corrosive injury, foreign body ingestion or surgery. A total of 12 patients had a solitary tongue of squamous cell extension, three had two tongues and in addition, two had squamous islands. Hiatal hernia was present in all patients, Barrett's esophagus in six (37.5 %), and esophageal stricture in four. CONCLUSION: Squamous cell extension into the proximal stomach is a newly recognized mucosal abnormality with presently unknown clinical significance. This mucosal abnormality may represent an esophageal mucosal response to proximal gastric injury.     

食管胃结合部癌前病变和早期癌的研究进展

Siewert将在食管胃连接部上下5 cm范围内发生的肿瘤定义为食管胃结合部肿瘤,包括远端食管腺癌、真正意义上的贲门癌和近端胃癌。传统上认为远端食管腺癌起源于Barrett食管黏膜,与反流相关疾病关系密切;贲门腺癌起源于贲门黏膜,与幽门螺杆菌感染关系密切;而近端胃癌则与幽门螺杆菌和肠化具有较强的关联性。反流相关疾病、Barrett食管和肠上皮化生、幽门螺杆菌感染等与食管胃结合部肿瘤的关系一直是该部位肿瘤的研究热点,但是也存在强烈的争议。随着食管胃结合部解剖学和组织学发展成熟,结合早期发现该部位癌变倾向,使得关于食管胃结合部癌变的病因、分子机制、解剖学及组织学上的探讨越来越深入明朗。因此在早期发现该部位病变并加以干预可以有效地帮助临床和科研工作者解决困扰,同时显著提高肿瘤患者的生存率。     

Clinical outline of Barrett's esophagus

Barrett's esophagus is one of the important gastrointestinal disease in Europe and the United States. It was recognized as not only complication of reflux esophagitis, but also pre-malignant lesion of adenocarcinoma. Recently, realization of Barrett's esophagus is attentioned in Japan, because increasing of reflux esophagitis for westernization of eating habit, living habit and aging of the population. In this section, we present general consideration and clinical research of Barrett's esophagus. We expect Barrett's esophagus will gradually increase near the future and need to research abundantly about controversial point of Barrett's esophagus. We also think it is important to accumulate intensively the clinical data of Barrett's esophagus patients.     

Videoendoscopy and histopathology of the esophagogastric junction in patients with gastroesophageal reflux disease

BACKGROUND AND AIMS: During endoscopy the stomach is considered to rise at the level of the 'gastric' folds; however, anatomical studies have demonstrated that the proximal gastric folds may in fact be esophageal. This prospective study was designed to assess the histopathology of endoscopically visible proximal gastric folds in patients with gastroesophageal reflux disease. METHODS: 35 consecutive patients (20 males) with gastroesophageal reflux disease underwent video endoscopy, including biopsy sampling from the endoscopically visible esophagogastric junction (0 cm, 0.5 cm and 1.0 cm distal to the rise of gastric folds and 0.5 cm and 1.0 cm proximal to it). Endoscopy was digitally recorded and reviewed for assignment of biopsy level. Columnar-lined esophagus and esophagitis were cataloged according to the Paull-Chandrasoma histopathologic classification and the Los Angeles endoscopic classification. RESULTS: Endoscopy: Normal endoscopic esophagogastric junction was seen in 11 (31%) patients and visible columnar-lined esophagus < or = 0.5 cm in 24 (69%). Histology: Columnar-lined esophagus extended 1.0 cm in 22.8% of patients and 0.5 cm in 51.4%, distal to the rise of the gastric folds. In all patients columnar-lined esophagus was interposed between squamous epithelium and gastric oxyntic mucosa. Thus, so-called gastric folds contained mucosa of esophageal origin in all patients. Intestinal metaplasia (Barrett esophagus) was detected in eight (22.9%) patients. CONCLUSIONS: Endoscopy cannot exclude histopathologic columnar-lined esophagus within gastric rugae. Thus, visible 'gastric' folds should not be used for definition of the esophagogastric junction but as a reference landmark for biopsy sampling during endoscopy.     

The definition of Barrett's esophagus

Recently, according to increasing gastroesophageal reflux disease (GERD), the patients with Barrett's esophagus (BE) are increasing. Since Barrett have reported cases of esophageal ulcers surrounding by columnar epithelium, the various criteria of the BE have been proposed. In 1998, practice guidelines for BE were developed under the auspices of the American College of Gastroenterology. They proposed that BE was a chance in the esophageal epithelium of any length that can be recognized at endoscopy, and confirmed to have intestinal metaplasia by biopsy of the tubular esophagus and excludes intestinal metaplasia of the cardia. Endoscopically, BE is determined, when 'gastric-appearing mucosa' or apparent 'columnar lined esophagus' is evident proximal to the esophagogastric junction. Histologically, BE has double muscularis mucosae, and contains a mixture cell types; gastric-fundic type epithelium, junctional type epithelium, and specialized columnar epithelium (SCE). Especially SCE is distinctive features of BE, available for diagnosis. On the other hand, BE is premalignant condition for the adenocarcinoma of the esophagus, therefore the features of the BE are researched to prevent and find out earlier development of adenocarcinoma. In this review, we referred to the definition of BE with some topics.     

Biopsy methods and pathology of Barrett's esophagus

We reviewed the definition of the esophagogastric junction and the biopsy sites and histologic findings of biopsy specimens from Barrett's esophagus. The borderline between the esophagus and stomach has been defined as the distal limit of the longitudinal vessels by the Japan Esophageal Society, because the longitudinal vessels are always located within the esophagus. As squamous islands in Barrett's mucosa are usually the orifices of esophageal glands proper, biopsy specimens from the squamous islands show esophageal glands proper or their ducts. The identification of esophageal glands proper is a definite histological indicator that a piece of biopsy tissue is of esophageal origin. Therefore, a diagnosis of Barrett's esophagus can be made purely on the basis of the histologic findings in these biopsy specimens of squamous islands. Since columnar mucosa is usually recognizable at endoscopy, a diagnosis of Barrett's esophagus can be made solely on the basis of endoscopic examination, without any need for histologic confirmation, if squamous islands are recognized in columnar-lined mucosa.     

Barrett's esophagus

The Barrett's esophagus showing columnar metaplasia upward to the esophagus from the esophago-gastric junction is one of the final appearance of reflux esophagitis and important as a precancerous state of esophageal adenocarcinoma. Especially the Barrett's mucosa with intestinal metaplasia has high potential risk for adenocarcinoma. Although the clinical definition of the esophago-gastric junction is not easy, the criteria of the esophago-gastric junction and the Barrett's mucosa proposed by the Japanese Society for Esophageal Diseases is useful. The gastro-esophageal reflux is important in the development of Barrett's mucosa not only in the classical Barrett's esophagus but also in the short-segment Barrett's.     

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.     

Methylene blue chromoendoscopy for the detection of Barrett's esophagus in a Greek cohort

BACKGROUND AND STUDY AIMS: Specialized columnar epithelium of Barrett's esophagus is a precursor of dysplasia and adenocarcinoma, and methylene blue selectively stains this type of epithelium. The present prospective study examined the detection of short-segment and long-segment Barrett's esophagus using methylene blue chromoendoscopy-directed biopsies, in comparison with biopsies directed using conventional endoscopic criteria. PATIENTS AND METHODS: Biopsies were obtained from macroscopically conspicous areas in the distal esophagus observed during conventional endoscopy in a total of 975 patients. Immediately after conventional biopsies, the distal esophagus was sprayed with methylene blue and directed biopsies were then obtained from the stained regions. All patients with a histologically established Barrett's esophagus underwent a second upper gastrointestinal endoscopy within 1 year in order to assess the reproducibility of the method. RESULTS: In a total of 3,900 conventional biopsy specimens (without staining), 54 specimens (1.4%) were found to show Barrett's esophagus and were confined to 16 of the 975 patients (1.6%). Of the total 130 directed biopsy specimens obtained during chromoendoscopy, 114 (87.7%) revealed Barrett's esophagus (P<0.00001) and were confined to 35 of the 975 patients (3.5%; P < or = 0.001). The findings were confirmed within 1 year in all dye-positive patients. CONCLUSIONS: Chromoendoscopy with methylene blue appears to be an accurate, simple, safe, inexpensive, and reproducible method of detecting specialized columnar epithelium in Barrett's esophagus.     

Management of malignant stricture of the esophagogastric junction with a newly designed self-expanding metal stent with an antireflux mechanism

BACKGROUND AND STUDY AIMS: When stents are placed across the esophagogastric junction for palliative treatment of malignant strictures, they may lead to esophagogastric reflux. The aim of this study was to compare the effectiveness of a newly designed antireflux stent with that of a standard open stent and a currently available antireflux stent (Dostent) in preventing gastroesophageal reflux symptoms in patients with inoperable cancer at the esophagogastric junction. PATIENTS AND METHODS: Thirty-six consecutive patients with cancer at the esophagogastric junction were randomly assigned to undergo placement of a newly designed antireflux stent (n = 12), a Dostent (n = 12), or a standard open stent (n = 12). Technical and clinical success, dysphagia score, reflux symptoms, complications and ambulatory 24-h esophageal pH monitoring were assessed. RESULTS: The technical success rates were 100 %. After 1 week, dysphagia had improved in all patient groups ( P < 0.05), but the degree of improvement did not differ between the three groups. The DeMeester score was significantly lower in the group with the newly designed antireflux stent than in the other groups. The fraction of the total recording time during which esophageal pH was below 4 was 3.14 +/- 5.78 % using the newly designed antireflux stent, in comparison with 29.25 +/- 15.41 % in the Dostent group and 15.01 +/- 11.72 % in the standard open stent group ( P < 0.001). Fewer reflux episodes occurred with the newly designed antireflux stent than with the Dostent or standard open stent. There were no complications with any of the three stents. CONCLUSIONS: The newly designed antireflux stent is effective in relieving dysphagia caused by malignant cancer at the esophagogastric junction. The newly designed antireflux stent is significantly more effective in preventing gastroesophageal reflux than currently available antireflux stents.     

Barrett食管的病理本质及其与返流性食管炎,食管腺癌关系的研究

从１０００例食管粘膜咬检及１５８０例食管贲门癌切除标本中交界处癌１６５例的形态学、粘液组化及ＦＣＭ分析，探讨ＢＥ病理本质及其与返流性食管炎、食管腺癌的关系。结果：１０００例咬检中２２７例有不同程度的返流性食管炎，其中３例符合ＢＥ。１５８０例食管贲门癌中，交界处癌２３例（１．５％）为食管腺癌，１３例（５６．５％）根据部位、形态、粘液组化分析证明为ＢＥ来源的腺癌。本文认为慢性胃液返流使食管粘膜鳞状上皮长期受损，修复中，部分病例食管鳞状上皮由邻接耐酸性较强、增殖更活跃的胃贲门上皮向上异位生长而代替。长期非特异性刺激附加致癌因素刺激下，修复性增生转变为渐进性异型增生，最终导致癌变，形成ＢＥ来源的腺癌。     

Barrett's esophagus and esophageal adenocarcinoma: the scope of the problem

Conclusion Barrett's esophagus is probably a more common condition than previously recognized. Although the classic radiologic findings of Barrett's esophagus are present in only a small percentage of patients, this condition should be suspected whenever reflux esophagitis or peptic strictures are demonstrated on double-contrast esophagography. Recent literature also suggests that Barrett's carcinomas comprise up to 50% of all esophageal cancers. Because of the increased risk of developing adenocarcinoma in Barrett's esophagus, endoscopic surveillance has been advocated to detect dysplastic or carcinomatous changes at the earliest possible stage. When barium studies are performed on patients with known Barrett's esophagus, the radiographs should be carefully evaluated for signs of early adenocarcinoma, so these patients can be referred for appropriate management prior to the development of advanced, unresectable tumors.     

Frequency of Barrett's neoplasia after initial negative endoscopy with biopsy: a long-term histopathological follow-up study

BACKGROUND: Barrett's adenocarcinoma is being diagnosed increasingly. We examine possible differences between long segment and short-segment Barrett esophagus (LSBE and SSBE) in long-term follow-up on the basis of our histopathology registry. METHODS AND PATIENTS: All Barrett's esophagus patients diagnosed histologically between 1990 and 1995 (n = 1071) were selected. Long-term follow-up data from endoscopy with biopsy were sought on all patients without neoplasia on initial endoscopic biopsy (n = 1003). A total of 255 individuals (25.4 %) were regarded as drop-outs (201 lost and 54 without further endoscopy). Of the remaining 748 patients with follow up for more than 5 years, 315 had documented LSBE, 246 had SSBE, and 187 had no length of Barrett esophagus recorded (NLBE). RESULTS: In the study cases (male : female ratio 2.1 : 1, mean age +/- SD 60.9 +/- 14.2 years), the biopsy procedure was fully compliant with guidelines in only 32.5 %. Only 5 cases (0.6 %) had visible lesions reported on endoscopy, but all were negative for neoplasia. Over a mean follow-up of 78.2 +/- 35.6 months (range 0-240), 7 new cases of low grade intraepithelial neoplasia (LGIN) and 15 cancer cases developed, accounting for a yearly incidence of 0.2 % (LGIN) or 0.4 % (cancer) after an initial negative endoscopy. When the cases with initial diagnosis of neoplasia were included, this yearly incidence rose to 0.5 % (LGIN), 0.3 % (high grade intraepithelial neoplasia [HGIN]) or 1.7 % (cancer). Differences between SSBE and LSBE were only encountered for cancer incidence. CONCLUSION: The yearly incidence of Barrett esophagus cancer varies between 0.4 % and 1.7 %. Despite the limitations of this retrospective and pathology-based study, the observed risk of developing cancer in Barrett esophagus without neoplasia is comparable to that found in other studies, mainly from the US and the UK, and varies between 0.7 % and 1.0 % of yearly incidence.     

Esophagogastric ring: why and when we see it, and what it implies: a radiologic-pathologic correlation.

Schatzki first reported a ring-like structure at the esophagogastric mucosal junction in 1953. There is still no uniform agreement as to its exact location, etiology, or clinical importance. We found an esophagogastric ring in 15% to 18% of 22,368 patients having routine upper gastrointestinal examinations. It was present only in patients with cephalad displacement of the esophagogastric junction and only in those who had sharply and circumferentially marginated transition of esophagogastric mucosal junction. It is postulated that the esophagus shortens on vagal stimulation by contracture of the longitudinal esophageal muscle, which causes a mucosal infolding at the esophagogastric junction. In a small group of these patients, fibrosis apparently develops in this region and results in a fixed organic circumferential diaphragm, which may cause obstructive symptoms. These concepts affect therapeutic alternatives.     

Intraepithelial high-grade neoplasia and early adenocarcinoma in short-segment Barrett's esophagus (SSBE): curative treatment using local endoscopic treatment techniques

BACKGROUND AND STUDY AIMS: In recent years, short-segment Barrett's esophagus (SSBE) has attracted increasing attention in the context of reflux disease. However, there is continuing controversy regarding its potential for malignant transformation. PATIENTS AND METHODS: Between October 1996 and September 1999, 50/115 patients (43 %) with intraepithelial high-grade neoplasia or early Barrett's adenocarcinoma, who underwent local endoscopic treatment, had developed a malignant lesion in an (SSBE). In the framework of a prospective observational study, 28 patients were treated with endoscopic mucosal resection (EMR), 13 with photodynamic therapy, and three with argon plasma coagulation; six patients received combinations of these treatments. RESULTS: Complete local remission was achieved in 48/49 patients (98 %). One patient switched to surgery after the first EMR, because there was submucosal tumor infiltration, and in one patient out of 50 local endoscopic treatment failed. A mean of 1.7 +/- 1.4 treatment sessions was required for local endoscopic treatment. The method-associated mortality was 0 %. The rate of relevant complications (stenosis, bleeding) was 6 % (3/50 patients). No cases of severe hemorrhage (Hb fall >2 g/dl) or perforation occurred. During a mean follow-up period of 34 +/- 10 months, metachronous intraepithelial high-grade neoplasms or early adenocarcinomas were seen in 11/48 patients (23 %), who received further successful endoscopic treatment. Four patients died during the follow-up period, but in only one patient was this due to his Barrett's adenocarcinoma (this was the patient who underwent esophageal resection). CONCLUSIONS: The malignant potential of short-segment Barrett's esophagus must not be underestimated. Organ-preserving local endoscopic treatment shows good acute-phase and long-term results. Local endoscopic treatment represents an alternative to esophageal resection in the case of intraepithelial high-grade neoplasia and selected early adenocarcinomas in Barrett's esophagus.     

Barrett's esophagus

Gastroesophageal reflux disease (GERD) is a condition commonly managed in the primary care setting. Patients with GERD may develop reflux esophagitis as the esophagus repeatedly is exposed to acidic gastric contents. Over time, untreated reflux esophagitis may lead to chronic complications such as esophageal stricture or the development of Barrett's esophagus. Barrett's esophagus is a premalignant metaplastic process that typically involves the distal esophagus. Its presence is suspected by endoscopic evaluation of the esophagus, but the diagnosis is confirmed by histologic analysis of endoscopically biopsied tissue. Risk factors for Barrett's esophagus include GERD, white or Hispanic race, male sex, advancing age, smoking, and obesity. Although Barrett's esophagus rarely progresses to adenocarcinoma, optimal management is a matter of debate. Current treatment guidelines include relieving GERD symptoms with medical or surgical measures (similar to the treatment of GERD that is not associated with Barrett's esophagus) and surveillance endoscopy. Guidelines for surveillance endoscopy have been published; however, no studies have verified that any specific treatment or management strategy has decreased the rate of mortality from adenocarcinoma.     

Argon plasma coagulation in the treatment of Barrett's high-grade dysplasia and in situ adenocarcinoma

BACKGROUND AND STUDY AIMS: Endoscopic therapy of high-grade dysplasia (HGD) and superficial adenocarcinoma associated with Barrett's esophagus (BE), using Nd:YAG laser, KTP laser, or photodynamic therapy (PDT), has been reported to be effective in a curative role. Argon plasma coagulation (APC) appears to be effective in the eradication of nondysplastic Barrett's mucosa, but no results are available in the management of early neoplasms complicating BE. We report our initial experience in the application of APC in this indication. PATIENTS AND METHODS: Ten patients (mean age 74.2) with histologically proven HGD (n = 7) or in situ adenocarcinoma (n = 3) associated with BE (mean length 6 cm) and unfit for surgery were treated using APC and high-dose omeprazole (40 mg daily) until squamous re-epithelialization or complete eradication of the initially apparent lesions. Endoscopic follow-up was maintained at every 3 months. RESULTS: Complete eradication of HGD and in situ adenocarcinoma was achieved after a mean number of 3.3+/-1.5 APC sessions in 8/10 patients (80%). The eight patients with complete clearance of the neoplastic areas did not show any evidence of local recurrence during a median follow-up of 24 months (range 12-36 months). One patient with initial HGD had persistence of HGD 30 months after initial diagnosis, and one patient progressed to invasive adenocarcinoma after failure of APC and PDT. CONCLUSIONS: APC is safe and effective in the management of HGD and in situ adenocarcinoma associated with BE, and might represent an interesting alternative in selected patients who are not candidates for surgery.     

Histopathology of columnar-lined esophagus in patients with gastroesophageal reflux disease

BACKGROUND AND AIMS: The question of whether an endoscopically normal-appearing esophagogastric junction should be biopsied in patients with gastroesophageal reflux disease is controversial. We have addressed this issue using endoscopy and histopathology. METHODS: A total of 114 consecutive patients (58 males) with symptoms of gastroesophageal reflux disease prospectively underwent endoscopy, including biopsy sampling from the esophagogastric junction. Endoscopically visible columnar-lined esophagus was defined by the presence of gastric-type mucosa above the level of the rise of the gastric folds. Histopathology was conducted using the Paull-Chandrasoma classification. RESULTS: Of the 114 patients, 85 (74.6%) had endoscopically visible columnar-lined esophagus of length < or =0.5 cm (n = 82), 1 cm (n = 2) and 7 cm (n = 1); 29 patients (25.4%) had a normal endoscopic junction. All patients had histopathologic columnar-lined esophagus. Intestinal metaplasia and low-grade dysplasia was identified in 26 (22.8%) and 5 (4.4%) individuals, respectively, and was not statistically different in endoscopically normal vs. abnormal junction (P = 0.408 for intestinal metaplasia, P = 0.775 for low grade dysplasia). Intestinal metaplasia was independent from endoscopic esophagitis (P = 0.398) and hiatal hernia (P = 0.405). CONCLUSIONS: Columnar-lined esophagus cannot be excluded by endoscopy. In patients with gastroesophageal reflux disease, biopsy sampling of normal-appearing junction is recommended for histopathologic exclusion of intestinal metaplasia and low-grade dysplasia.     

The burden of upper gastrointestinal endoscopy in patients with Barrett's esophagus

BACKGROUND AND STUDY AIMS: Patients with Barrett's esophagus are recommended to undergo regular surveillance with upper gastrointestinal endoscopy, an invasive procedure that may cause anxiety, pain, and discomfort. We assessed to what extent patients perceived this procedure as burdensome. PATIENTS AND METHODS: A total of 192 patients with Barrett's esophagus were asked to fill out questionnaires at 1 week and immediately before endoscopy, and at 1 week and 1 month afterwards. Four variables were assessed: (i) pain and discomfort experienced during endoscopy; (ii) symptoms; (iii) psychological burden, i. e., anxiety, depression and distress levels (Hospital Anxiety and Depression scale, Impact of Event Scale); and (iv) perceived risk of developing adenocarcinoma. RESULTS: At least one questionnaire was returned by 180 patients (94 %), 151 completed all four (79 %). Of all patients, only 14 % experienced the endoscopy as painful. However, 59 % reported it to be burdensome. Apart from an increase in throat ache (47 % after endoscopy versus 12 % before), the procedure did not cause physical symptoms. Patients' anxiety, depression, and distress levels were significantly increased in the week before endoscopy compared with the week after. Patients perceiving their risk of developing adenocarcinoma as high reported higher levels of psychological distress and that the procedure was a greater burden. CONCLUSIONS: Upper gastrointestinal endoscopy is burdensome for many patients with Barrett's esophagus and causes moderate distress. Perception of a high risk of adenocarcinoma may increase distress and the burden experienced from the procedure. The benefits of endoscopic surveillance for patients with Barrett's esophagus should be weighed against its drawbacks, including the short-term burden for patients.     

Diagnosis of esophagogastric tumors

It has been suggested that certain histological criteria may serve to indicate a good prognosis in patients with esophageal carcinoma. These include absence of subepithelial extension of the carcinoma cells, stage no higher than m2, and no neoplastic involvement near the resection margin. As endoscopic mucosal resection is becoming an accepted treatment option in this type of tumor, prognostic parameters of this type are of particular interest. By contrast, when metastases are detected in the celiac lymph nodes, it implies that the tumor is unresectable and that palliative treatment is required. Endoscopic ultrasound (EUS)-guided fine-needle aspiration has been found to be the most cost-effective option in this setting. Although autofluorescence endoscopy is being tested as a new technique for endoscopic diagnosis, its value is at present unclear. However, such developments may lead to improved diagnosis in the future, particularly in relation to the initial stages of carcinoma. For the moment, EUS is still the most widely accepted method for early diagnosis and staging. Esophageal squamous-cell carcinoma appears to be commonly associated with head and neck cancer, but the cost-effectiveness of surveillance is a matter of controversy. With regard to Barrett's esophagus and adenocarcinoma, p53 staining in areas of low-grade dysplasia appears to be helpful for predicting progression to high-grade dysplasia. The prevalence of short-segment Barrett's esophagus increases with age, but the length of the segment does not increase with time; the length probably depends on individual conditions, not merely on elapsed time. Helicobacter pylori infection appears to be associated with intestinal metaplasia at the esophagogastric junction. However, the most recent data appear to suggest that this scenario (usually termed "carditis") may be different from intestinal metaplasia in the lower esophagus, related to acid reflux. A follow-up program might be able to detect Barrett's esophagus adenocarcinoma at earlier stages, but only a minority of Barrett's esophagus patients are likely to be detected before neoplasia has developed. Gastric cancer appears to develop in individuals with H. pylori infection, but not in uninfected persons. In addition, those with severe gastric atrophy, corpus-predominant gastritis, and intestinal metaplasia may be at greater risk for gastric cancer. This again raises the question of H. pylori eradication in asymptomatic individuals with infection, and surveillance of patients with severe intestinal metaplasia. The most recent data appear to support the notion that healing of MALT lymphoma depends not only on H. pylori eradication and on the stage of the tumor, but also on individual factors (possibly immunology-related).