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.     

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.     

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.     

Circumferential endoscopic mucosal resection in Barrett's esophagus with high-grade intraepithelial neoplasia or mucosal cancer. Preliminary results in 21 patients

BACKGROUND AND STUDY AIMS: Treatment by endoscopic mucosal resection (EMR) has been established for early lesions in Barrett's esophagus. However, the remaining Barrett's esophagus epithelium remains at risk of developing further lesions. The aim of this study was to evaluate the efficacy of circumferential endoscopic mucosectomy (circumferential EMR)s in removing not only the index lesion (high-grade intraepithelial neoplasia (HGIN) or mucosal cancer), but also the remaining Barrett's esophagus epithelium. PATIENTS AND METHODS: A total of 21 patients were included in the study (11 men, 10 women), who had Barrett's esophagus and either HGIN (n = 12) or mucosal cancer (n = 9). Of the patients, 17/21 were at high surgical risk and five had refused surgery. On the basis of preprocedure endosonography their lesions were classified as T1N0 (n = 19) or T0N0 (n = 2). The lesions and the Barrett's esophagus epithelium were removed by polypectomy after submucosal injection of 10-15 ml of saline; a double-channel endoscope was used in 15/21 cases. Circumferential EMR was performed in two sessions, the lesion and the surrounding half of the circumferential Barrett's esophagus mucosa being removed in the first session. In order to prevent the formation of esophageal stenosis, the second half of the Barrett's esophagus mucosa was resected 1 month later. RESULTS: Complications occurred in 4/21 patients (19 %), consisting of bleeding which was successfully managed by endoscopic hemostasis in all cases. No strictures were observed during follow-up (mean duration 18 months) and endoscopic resection was considered complete in 18/21 patients (86 %). For three patients, histological examination showed incomplete removal of tumor: one of these underwent surgery; two received chemoradiotherapy, and showed no evidence of residual tumor at 18 months' and 24 months' follow-up, respectively. Two patients in whom resection was initially classified as complete later presented with local recurrence and were treated again by EMR. Barrett's esophagus mucosa was completely replaced by squamous cell epithelium in 15/20 patients (75 %). CONCLUSIONS: Circumferential EMR is a noninvasive treatment of Barrett's esophagus with HGIN or mucosal cancer, with a low complication rate and good short-term clinical efficacy. Further studies should focus on long-term results and on technical improvements.     

Diagnosis of Barrett's esophagus by pertechnetate radionuclide.

In Barrett's esophagus the normal stratified squamous epithelium of esophagus is replaced by columnar epithelium and other charcteristics of gastric mucosa. Barrett's esophagus has an increased tendency to bleed and is more prone to undergo malignant change. There are many procedures used to diagnose this entity, but only by serial and multiple esophageal mucosal biopsies can the diagnosis be confirmed. Harper et al (2) demonstrated an early and intense uptake of 99m Tc pertechnetate by the stomach in animals. Since the Barrett's esophagus is lined by gastric mucosa, pertechnetate scintigraphy was used as a screening procedure. The criteria for a postive scan was an area of increased uptake of technetium extending above the normal dense uptake of stomach configuration. Pertechnetate scintigraphy was performed in 4 patients with Barrett's esophagus and 6 controls with only one false negative result. Thus pertechnetate scintigraphy is a rapid, safe, and atraumatic screening procedure.     

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.     

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.     

Detection of Barrett's epithelium by acoustic microscopy

Barrett's esophagus is associated with increased risk of adenocarcinoma of the gastroesophageal junctional region. The presence of goblet cells (intestinal metaplasia) in columnar cell-lined esophageal mucosa defines Barrett's change. The diagnosis of Barrett's esophagus is based on the presence of intestinal metaplasia in a biopsy from an endoscopically visualized abnormal columnar epithelium. In this pilot study, acoustic microscopy was used to identify the mucosal structure of 10 distal esophageal biopsies. Sections cut at 5 microm of archival paraffin blocks on glass slides were used for this study. Acoustic microscopy permitted the identification of low- and high-power images of epithelial architecture and cellular detail, including Barrett's epithelium. This modality of visualization has the potential to detect lesions such as Barrett's metaplasia, low- and high-grade dysplasia and early carcinoma. If it can be applied to in vivo endoscopy, acoustic microscopy has the potential to increase the accuracy of the diagnosis of Barrett's esophagus, dysplasia and malignancy by providing a method of accurately directing biopsies at endoscopy.     

Endoscopic ultraviolet-induced autofluorescence spectroscopy of the esophagus: tissue characterization and potential for early cancer diagnosis

BACKGROUND AND STUDY AIMS: Endoscopic identification of dysplasia and early carcinoma of the esophagus is difficult and is currently done through random pinch biopsies. This study assesses the potential of ultraviolet-induced autofluorescence spectroscopy for early diagnosis with special focus on Barrett's esophagus. PATIENTS AND METHODS: Measurements were performed on 24 patients using 330 nm light excitation. The determination of the spectral distribution typical of each histological tissue type was done using three fluorescence intensity ratios: RI = I390nm/I450nm; R2 = I550nm/I450nm; R3 - I390nm/I550nm. RESULTS: The spectral distribution of normal esophageal mucosa and specialized columnar Barrett's mucosa were similar. A strong modification of the spectral distribution was observed for high grade dysplasia and intramucosal carcinoma. Statistical analysis indicated that the spectral shape modification associated with neoplastic transformation was greater than intra- and interpatient spectral variations. These results allow the determination of discriminating criteria based on ratios R1 and R3. Using ratio R3, the spectroscopy-based diagnosis differentiated neoplastic tissue from normal esophageal mucosa and specialized columnar Barrett's mucosa with a sensitivity and specificity of 86% and 95 %, respectively. CONCLUSIONS: The use of ultraviolet autofluorescence spectroscopy should improve the diagnostic yield of standard endoscopy in patients with 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.     

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.     

Barrett's esophagus complicating scleroderma

Two patients with scleroderma whose esophageal involvement was associated with longstanding reflux esophagitis were found to also have Barrett's esophagus. Since Barrett's esophagus is a premalignant condition, these patients with scleroderma should be considered at high risk for the development of adenocarcinoma of the esophagus.     

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.     

Esophageal complications of gastroesophageal reflux disease: presentation, diagnosis, management, and outcomes

The esophageal complications of gastroesophageal reflux disease include peptic esophageal erosion and ulceration, peptic esophageal strictures, and Barrett's esophagus. Endoscopy is the diagnostic procedure of choice for the initial evaluation of lesions. For most patients, symptoms can be controlled with proton pump inhibitor (PPI) therapy. PPIs are also highly effective for healing esophageal erosions and ulcerations and for preventing recurrence of peptic esophageal strictures. Because Barrett's esophagus predisposes individuals to esophageal adenocarcinoma, these patients are advised to have regular endoscopic surveillance to detect early, curable neoplasms.     

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.     

Squamous reepithelialization after circumferential endoscopic mucosal resection of superficial carcinoma arising in Barrett's esophagus

Recent reports on the results of endoscopic ablation of Barrett's mucosa have been promising, particularly when total mucosal ablation is coupled with aggressive acid-suppression treatment using high-dose proton-pump inhibitor therapy. There is also a considerable literature on reepithelialization after ablative treatments in Barrett's esophagus. This report describes a case of multifocal superficial adenocarcinoma arising in Barrett's mucosa that was successfully treated with total circumferential endoscopic mucosal resection, with a subsequent follow-up of more than 2 years. This is the first report describing the process of squamous reepithelialization after endoscopic mucosal resection in Barrett's esophagus.     

The clinical strategy for the Barrett's esophagus

The treatment of Barrett's esophagus is controversial. Current treatments include endoscopic therapy, surgical procedures, gastric acid-suppressive therapy with proton pump inhibitors (PPIs), and cancer chemoprevention such as nonsteroidal anti-inflammatory drugs. Endoscopic therapy combined with gastric acid suppressive therapy can result in squamous reepithelialization of the Barrett's mucosa. Antireflux surgery and PPIs therapy are potential options for the treatment of gastroesophageal reflux symptoms in patients with Barrett's esophagus. But there are no prospective studies that support any alternative approach to treatment. Although chemoprevention therapy may reduce cancer risk in Barrett's esophagus, no randomized controlled trials that prove its efficacy have been reported.     

Surgical therapies in Barrett's esophagus

The two main aspects relevant to the role of surgery in the management of patients with Barrett's esophagus are to define the role of surgery in controlling reflux and associated symptoms and to define the surgical options in case of dysplasia or early neoplasia. This article also will address the issue of whether complete reflux control in patients with Barrett's esophagus can prevent the metaplastic mucosa from further progression to dysplasia and adenocarcinoma.     

The economic burden of Barrett's esophagus in a Medicaid population

OBJECTIVE: To estimate the overall healthcare expenditures of patients with Barrett's esophagus in the West Virginia Medicaid population. METHODS: West Virginia Medicaid-paid claims data for the period January 1, 1995, to December 31, 1999, were used for the study. The population included all individuals eligible for West Virginia Medicaid during the study period except for Medicare eligible- and Medicaid managed-care recipients. A prevalence-based approach was used to determine the cost of illness for Barrett's esophagus. RESULTS: The total cost of illness for Barrett's esophagus more than tripled, from $182399 in 1995 to $623864 in 1999, with approximately a 4(1/2)-fold increase in medical and more than a threefold increase in pharmacy costs. The average cost of treating Barrett's esophagus was found to be approximately $1207 per patient in 1999. Overall, pharmacy costs accounted for >66% of the total costs. Controlling for age, gender, and number of comorbidities, patients with Barrett's esophagus incur 21.2% higher overall costs than patients with gastroesophageal reflux disease and 62.4% higher overall costs than the general Medicaid population. CONCLUSIONS: The increasing prevalence of and resource utilization for Barrett's esophagus provide a framework for further analysis and implementation of policies aimed at appropriate allocation of resources for the state's Medicaid program.