Ethnic Differences in the Prevalence of Endoscopic Esophagitis and Barrett's Esophagus: The Long and Short of It All

Recent studies indicate that the prevalence of gastroesophageal reflux disease in Asia is either increasing or better recognized. There is a paucity of reliable data on the prevalence of reflux disease in the various races in general and in Malaysia, in particular. The prevalence of erosive esophagitis and Barrett's esophagus in a multiethnic Malaysian population was studied, as well as the relationship of various factors associated with reflux disease. Chinese, Malay, and Indian patients undergoing gastroscopy in a tertiary referral center were assessed for the presence of esophagitis, hiatus hernia, and Barrett's esophagus. Patient demographics and risk factors associated with gastroesophageal reflux disease were also documented. The prevalence of endoscopically documented esophagitis among 1985 patients was 6.1%, the majority of which were mild, Grade I or II (88%). There was a preponderance of Indians with esophagitis, as well as males (P<0.05) and those with the presence of a hiatus hernia (P<0.01). Long-segment Barrett's esophagus was found in 1.6% of patients, and short-segment Barrett's in 4.6%. Indians had the highest prevalence of Barrett's esophagus compared with Chinese (P<0.05) or Malays (P<0.01). Hiatus hernia and erosive esophagitis were both positively associated with Barrett's metaplasia (P<0.01). A significant proportion of Malaysian patients undergoing endoscopy has mild reflux esophagitis and Barrett's esophagus. Indian ethnicity and the presence of a hiatus hernia were significantly associated with endoscopic esophagitis and Barrett's metaplasia. These observed racial differences warrant further study.     

Increased Barrett's Esophagus for the Decade Between 1991 and 2000 at a Single University Medical Center

Barrett's esophagus is being diagnosed increasingly in the United States. The aim of this study was to determine whether the increased diagnosis of Barrett's esophagus is due to endoscopic reporting and/or a truly increasing rate. This retrospective study reviewed 18,183 endoscopy reports at Temple University Hospital from January 1991 through December 2000. Annual rates of new cases of endoscopically suspected Barrett's esophagus were determined. Biopsy results were reviewed for the diagnosis of Barrett's esophagus (i.e., specialized intestinal metaplasia). Rates of Barrett's esophagus increased from 3.22 to 8.28 per 100 endoscopies (257%; P < 0.01) on endoscopy and from 0.67 to 2.76 per 100 endoscopies (412%; P < 0.01) on histology from 1991 to 2000. Twenty-four and seven-tenths percent (252/1020) of patients suspected at endoscopy to have Barrett's esophagus were confirmed by histology. This study demonstrates an increasing rate of new cases of suspected Barrett's esophagus on endoscopy and confirmed Barrett's esophagus on histology over the last decade. The endoscopic impression of Barrett's esophagus was about four times higher than the confirmed diagnosis of Barrett's esophagus (intestinal metaplasia) on histology. This study was reported in abstract form at the American College of Gastroenterology in October 2003 and appeared in the American Journal of Gastroenterology 98 (Suppl):S16–S17, 2003.     

反流性食管炎、Barrett食管和食管腺癌中上皮钙粘蛋白的表达

目的：研究反流性食管炎（ＲＥ）,Ｂａｒｒｅｔｔ食管（ＢＥ）及食管腺癌（ＥＡＣａ）中上皮钙粘蛋白（Ｅ－ｃａｄｈｅｒｉｎ）的表达及其意义。方法：运用免疫组化法ＡＢＣ法检测了１３例ＲＥ,１７例ＢＥ,１１例ＥＡＣａ以及３０例正常食管粘膜（ＮＥ）中Ｅ－ｃａｄｈｅｒｉｎ的表达。结果：Ｅ－ｃａｄｈｅｒｉｎ在ＮＥ,ＲＥ,ＢＥ,ＥＡＣａ中表达呈逐渐降低趋势。     

Cytological Screening for Barrett's Esophagus Using a Prototype Flexible Mesh Catheter

The current cost of endoscopically screening patients with gastroesophageal reflux disease (GERD) and Barrett's esophagus (BE) is considerable. A nonendoscopic device that allows for screening of these patients would offer significant cost savings. This pilot study evaluates the utility of cytologically diagnosing BE using a prototype flexible mesh catheter. Patients with known BE undergoing indicated surveillance endoscopy were enrolled in the study. Cytology specimens were obtained using a prototype flexible catheter and were evaluated for the presence of glandular cells, goblet cells, squamous cells, inflammation, and dysplasia. Eleven patients with BE were enrolled in the study. None of the patients experienced complications. Specimens from eight patients (73%) were adequate for evaluation and seven of these patients (87.5%) had goblet cells diagnostic for BE. In conclusion, flexible mesh catheters potentially offer a sensitive, inexpensive, and minimally invasive approach to evaluating patients with GERD and BE.     

Prevalence of Barrett's esophagus in Korea

BACKGROUND: In contrast to Western countries, the prevalence of Barrett's esophagus (BE) is still believed to be very low in the Far East. The aim of the present paper was to assess the prevalence of BE in Korea. METHODS: Nine hundred and ninety-two consecutive patients undergoing their first diagnostic upper gastrointestinal endoscopies due to various indications were included from four university hospitals in Korea. Esophagus of each patient was examined during insertion of the endoscope with minimum air inflation. From subjects who were found, during endoscopy, to have columnar-lined esophagus, at least two biopsy samples were taken from the columnar epithelium. Patients exhibiting specialized columnar epithelium on histological examination were diagnosed as having BE. RESULTS: Among 992 patients, 108 cases (10.9%) were endoscopically diagnosed as short-segment BE, and three cases (0.3%) were endoscopically diagnosed as long-segment BE. However, only 36 patients (3.6%) met the histological criteria for BE. Among these patients, only one (0.1%) was histologically diagnosed as having long-segment BE. Reflux esophagitis, mostly in a mild degree, was found in 25.0% of the BE group, and 8.6% of the non-BE group (P = 0.0022). Hiatal hernias were more commonly found in the BE group than in the non-BE group (22.2% vs 8.9%, P = 0.0163). CONCLUSIONS: Although the prevalence of BE in Korea appears to be lower than the reported rates from Western countries, it may not be as low as was previously thought.     

Prevalence of Barrett's esophagus in Japan

Norman Barrett originally described two special conditions, namely, a congenital short esophagus with an intrathoracic gastric columnar lining and congenital gastric heterotropia in the esophagus with ulceration. Thereafter, these conditions began to be known as “Barrett's esophagus.” It is an acquired condition of esophageal columnar metaplasia following chronic gastroesophageal reflux, and the classical Barrett's esophagus has been defined as having a circumferential columnar metaplasia spreading minimally 3 cm or more upward from the esophagogastric junction, because the esophagogastric junction still tends to be difficult to recognize precisely. Recently, from the point of view of adenocarcinogenesis of the esophagus, the term and concept of short-segment Barrett's esophagus (SSBE) as a developing condition of the classical Barrett's esophagus and the confirmation of intestinal metaplasia has been required; however, the definition of Barrett's esophagus still remains controversial. In Japan, although the prevalence of short-segment Barrett's esophagus has been reported to vary considerably, from 1% to 52%, the prevalence of long-segment Barrett's esophagus (LSBE) tends to range from 0% to 2%, which is a quite lower rate than that observed in Western countries. The great difference in the prevalence of SSBE is caused by the differences in the criteria of the esophagogastric junction and the definition concerning the necessity of intestinal metaplasia. A universally accepted definition of Barrett's esophagus is thus needed to accurately determine its actual prevalence.     

Endoscopy and Barrett's Esophagus: Current Perspectives in the US and Japan

Barrett''s esophagus (BE) is a precancerous disease that can lead to esophageal adenocarcinoma (EAC). Recently, the incidence of EAC arising from BE has been increasing, and EAC has now become a threat in many countries. However, there are many gaps among the various countries in terms of definitions and concepts and these gaps prevent discussing BE on the same footing. In order to eradicate BE, it is a global necessity to fill in these remaining gaps. We focused on the gaps and reviewed recent evidence and trends as well as the background of gaps between the US and Japan as two of the leading countries in the field of medical research. We also review the rapid advances in endoscopic techniques in relation to both diagnosis and therapy that are considered to be useful to eliminate the gaps between countries.     

Barrett's esophagus: a retrospective analysis of 13 years surveillance

Background and Aims:  The incidence of esophageal adenocarcinoma has increased significantly. Barrett's esophagus (BE), a known precursor, has a high prevalence but only few patients with this condition progress to malignancy − surveillance and screening programs are controversial and lack proven efficacy. This retrospective analysis reviews the 13-year outcome for patients entered into a surveillance program.
Methods:  Data from patients with histologically proven Barrett's esophagus (1992–2003) that participated in a surveillance program were identified and analyzed retrospectively until 2005.
Results:  404/536 patients had Barrett's esophagus confirmed histologically of which 212 (53%) were followed in a surveillance program (mean 3.95 years per patient). This resulted in 749 gastroscopies (3.5/patient). Histologically, Barrett's mucosa was seen in 54%, low-grade dysplasia in 18%, ulcerations in 9%, high-grade dysplasia in 2%. No metaplasia was seen in 13%, no biopsy was obtained in 3%. Nine of 212 patients (4.3%) under surveillance developed esophageal cancer; two presented with symptoms, requiring gastroscopy outside the surveillance program (1/2 was operated successfully, one had advanced disease). In seven asymptomatic patients, cancer was detected on routine endoscopy; curative esophagectomy was performed in six. All patients who developed cancer were male and all but one patient had dysplasia or ulcerations on index endoscopy.
Conclusion:  During 13 years of Barrett's surveillance, 88% of all adenocarcinoma occurred in a subset of only 11% patients. To stratify surveillance for Barrett's esophagus, programs could focus on male patients with dysplasia or ulcerations on index endoscopy. However, the cost-effectiveness of this remains unproven.     

Use of a Novel Monoclonal Antibody in Diagnosis of Barrett's Esophagus

A novel monoclonal antibody (MAbDAS-1), that specifically reacts with colonic but not small intestinal epithelium, recognizes specialized columnar epithelium (SCE) in the esophagus. The frequency of its reactivity in biopsy specimens of patients with endoscopically suspected Barrett's Esophagus (BE) is examined. Fifty-two biopsy specimens of the distal esophagus from 38 patients were tested by immunoperoxidase method using MAbDAS-1. Fifty-four samples of cardia-type mucosa biopsied from the stomach were used as controls. Results were compared with histology and Alcian blue/high iron diamine (AB/HID). Of the 52 specimens, 29 had glandular epithelium and the rest had only squamous epithelium. Ten were diagnosed to have SCE by histology. All 10 samples reacted with MAbDAS-1 and with Alcian blue. Of the remaining 19 specimens, five also reacted with MAbDAS-1. None of the squamous epithelium and cardia specimens reacted with MAbDAS-1. MAbDAS-1 may detect intestinal metaplasia of the esophagus of colonic phenotype in the absence of histological evidence of SCE.     

Barrett＇s esophagus： Prevalence and risk factors in patients with chronic GERD in Upper Egypt

AIM： To determine the prevalence and possible risk factors of Barrett＇s esophagus （BE） in patients with chronic gastroesophageal reflux disease （GERD） in EI Minya and Assuit, Upper Egypt. METHODS： One thousand consecutive patients with chronic GERD symptoms were included in the study over 2 years. They were subjected to history taking including a questionnaire for GERD symptoms, clinical examination and upper digestive tract endoscopy. Endoscopic signs suggestive of columnar-lined esophagus （CLE） were defined as mucosal tongues or an upward shift of the squamocolumnar junction. BF was diagnosed by pathological examination when specialized intestinal metaplasia was detected histologically in suspected CLE. pH was monitored in 40 patients. RESULTS： BE was present in 7.3% of patients with chronic GERD symptoms, with a mean age of 48.3 ± 8.2 years, which was significantly higher than patients with GERD without BE （37.4 ± 13.6 years）. Adenocarcinoma was detected in eight cases （0.8%）, six of them in BE patients. There was no significant difference between patients with BE and GERD regarding sex, smoking, alcohol consumption or symptoms of GERD. Patients with BE had significantly longer esophageal acid exposure time in the supine position, measured by pH monitoring. CONCLUSION： The prevalence of BE in patients with GERD who were referred for endoscopy was 7.3%. BE seems to be associated with older age and more in patients with nocturnal gastroesophageal reflux.     

Prevalence and risk factors of Barrett's esophagus in Korea

BACKGROUND AND AIM: Barrett's esophagus (BE) is diagnosed when specialized intestinal metaplasia (SIM) is detected histologically in endoscopically suspected columnar-lined esophagus (CLE). It is a premalignant condition and plays a pivotal role in the development of esophageal adenocarcinoma. It has traditionally been believed to affect Asians less frequently. The aim of this study was to determine the prevalence of BE and possible associated risk factors in Korea. METHODS: A retrospective analysis of 70 103 patients who had undergone their first upper endoscopies was performed using computerized medical records. Of these, 696 (1%) patients had suspected CLE. After screening by telephone, 480 were enrolled. The clinical and endoscopic characteristics of histologically identifiable BE and endoscopically suspected CLE not confirmed by biopsy (suspected CLE without SIM) were investigated. RESULTS: Barrett's esophagus was present in 151 patients (0.22%) with a mean age of 53.8 +/- 10.9 years. BE was more commonly found in men. BE was associated with a set of features distinct from suspected CLE without SIM; older age, greater predominance of male sex, more frequent smoking history, and more frequent acid regurgitation symptom. CONCLUSIONS: Barrett's esophagus remains less common in Korea than in Western countries. Old age, male sex, smoking, and acid regurgitation symptom were significant risk factors.     

Prevalence of Campylobacter pylori in Patients Undergoing Upper Endoscopy

From August 1987 through July 1988, we evaluated antral biopsy specimens for Campylobacter pylori (CP) in 212 patients undergoing upper endoscopy. For those patients who had multiple endoscopies, the first endoscopy in which a urease test, histology, and culture were done was used to determine CP status. A patient was regarded as CP-positive if the culture was positive or if both a urease test and the histology were positive. Blacks had an increased CP positivity (61.2%) compared to whites (31.5%). Among non-ulcer patients, CP positivity was 52% in black patients and 18% in white patients. Age and gender were unrelated to CP positivity among controls and those without ulcers. There was increased CP positivity in patients with duodenal ulcers (85%), compared with those without ulcers (37%), and a trend toward increased positivity in those with gastric ulcer (53%) and duodenitis (50%). There was no increased CP positivity in patients with gastroesophageal reflux disease (28%), gastritis (29%), non-ulcer dyspepsia (43%), or the control patients with no gastroduodenal mucosal abnormalities (40%). CP-negative DU patients were older (average 71 yr) than CP-positive DU patients (43 yr), and female DU patients had a lower CP positivity (71%) than males (94%).     

Prevalence of Barrett's esophagus in an urban Korean population: a multicenter study

Background: It had been believed that over 75% of cases of esophageal carcinoma were squamous cell carcinoma (SCC). However, recently, in Western countries, the incidence of SCC has decreased, while the rate of adenocarcinoma has increased dramatically, accounting for almost 50% of esophageal carcinomas. With this change, concern over Barrett's esophagus (BE) has increased. Traditionally, it was believed that BE affected Asians less frequently. However, accelerated westernization has changed the lifestyle of Asians dramatically, and this raises the question that the prevalence might be changed in Asians living in Asia. Lacking reports on the prevalence of BE in the Korean population, we examined the data from endoscopic examinations performed at five referral hospitals in Seouls, Korea, to estimate the period prevalence of BE. Methods: One thousand five hundred and fifty-three patients who presented themselves to five referral hospitals due to various gastrointestinal symptoms prospectively underwent upper gastrointestinal endoscopic examinations and were enrolled in the study. Two biopsy specimens were taken from any parts of pink mucosa 3 cm or more above the squamocolumnar junction. Results: BE was detected in 5 of the 1553 patients who underwent upper gastrointestinal endoscopic examinations, and the approximate period prevalence of BE in Korean patients in the five referral hospitals was 3.2 per 1000. Of the 5 patients, two were men and three women with a mean age of 65 ± 11.8 (mean ± SD) years. All these patients had a body mass index (BMI) of less than 25 and were not obese. Regurgitation was described by 2 (40%) patients with BE, and heartburn was complained of by 4 (80%) patients. Of the 5 patients with BE, 3 (60%) patients had esophagitis, 2 (40%) patients had hiatal hernia, and none of the patients had Helicobacter pylori infection. The gross type of BE consisted of type I (spike) in 2 (40%) patients, type II (circumferential type II) in 1 (20%) patient, type III (circumferential type III) in 1 (20%) patient, and mixed type in 1 (20%) patient. Specialized intestinal metaplasia was found in all 5 patients. Conclusions: The period prevalence of BE among the patients of five referral hospitals was 3.2 per 1000, and it seems that the prevalence of BE in Korean urban area is lower than that in Western countries. Received: January 10, 2002 / Accepted: May 17, 2002 Acknowledgements. This study was supported by the grant from the Korean Society of Gastrointestinal Motility. Reprint requests to: H. Park     

内镜下碘染色对Barrett食管的诊断价值

目的 探讨内镜下碘染色对Barrett食管的诊断价值.方法 将内镜下考虑Barrett食管的病人82例随机分成两组,其中一组43例行碘染色后取活检,一组39例行常规内镜下活检.结果 43例经内镜下碘染色后活检,病理诊断Barrett食管的为29例(66.44%),而常规内镜下活检诊断Barrett食管的为13例(33.33%),碘染色组的检出率明显高于非染色组,且经ROC曲线分析,内镜下碘染色组的ROC曲线下面积、灵敏度、特异度、阳性预测值和准确度明显高于常规内镜检查组.结论 内镜下碘染色有助于提高Barrett食管的诊断率,在Barrett食管的诊断上具有重要的临床价值.     

Methylene Blue Staining and Endoscopic Ultrasound Evaluation of Barrett's Esophagus with Low-Grade Dysplasia

This study was performed to determine if either methylene blue staining or endoscopic ultrasound helped direct biopsies in patients with a history of Barrett's esophagus with low-grade dysplasia. Patients underwent radial endoscopic ultrasound scanning to measure esophageal wall thickness, followed by endoscopy with methylene blue staining and biopsies. Mean esophageal wall thickness for squamous mucosa (2.3 ± 0.2 mm), nondysplastic Barrett's (2.6 ± 0.2 mm), and Barrett's with dysplasia (2.9 ± 0.3 mm) were similar. With staining, Barrett's mucosa stained blue more often than gastric epithelium (68% vs 15%, respectively; P < 0.001). The sensitivity and specificity for strong staining detecting Barrett's were 68% and 85%, respectively. Barrett's with low-grade dysplasia stained blue less frequently (52%) than nondysplastic Barrett's (74%; P < 0.05), but the positive predictive value for poor staining indicating dysplasia was 41%. Endoscopic ultrasound was not helpful in directing biopsies in these patients. The utility of methylene blue for detecting dysplasia needs further investigation.     

Prevalence of Barrett's esophagus and expression of mucin antigens detected by a panel of monoclonal antibodies in Barrett's esophagus and esophageal adenocarcinoma in Japan

Barrett's esophagus (BE) is an acquired disorder associated with a high incidence of adenocarcinoma of the lower esophagus. Moreover, it has been reported that short-segment BE may be associated with adenocarcinoma of the esophagogastric junction. The objective of this study was to define the prevalence of BE and the mucin profile in BE, including the short-segment type, and to compare the mucin profile in BE with the profiles of Barrett's adenocarcinoma and distal esophageal adenocarcinoma among Japanese. In total, 650 adult subjects underwent endoscopic examination for evaluation of BE. Although the prevalence of traditional (long segment) BE was 0.62%, the overall prevalence of BE including short-segment type was 15.7%. In Barrett's epithelium, the short-segment type predominantly had gastric type mucin, while the middle- and long-segment types possessed intestinal mucin, especially colonic type mucin (sulfo-Lewis^a), with high frequency. In Barrett's epithelium with adenocarcinoma, all Barrett's epithelium adjacent to carcinomas showed a predominance of immunoreactivity to sulfo-Lewis^a. In Barrett's adenocarcinomas, colonic type mucin was detected in 100% by monoclonal antibody (MoAb) 91.9H. Small-intestinal mucin and gastric mucin were stained in 50% and 12.5% of the subjects, respectively. Colonic type mucin was also detected with high frequency (80%) in distal esophageal adenocarcinomas without Barrett's epithelium. These data suggest that the epitope, not of small-intestinal type or gastric type mucin, but of colonic type mucin (sulfo-Lewis^a), may be associated with, at least in part, the malignant phenotype of BE. Received: July 28, 1999 / Accepted: February 25, 2000     

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.     

Quantitative endoscopy in the chemoprevention of Barrett's Esophagus Trial

SUMMARY. The Chemoprevention for Barrett's Esophagus Trial (CBET) was a phase IIb, multicenter, randomized, placebo‐controlled trial of celecoxib in patients with Barrett's esophagus. The overall outcome of the study was that there were no significant differences in primary, secondary, or tertiary outcomes. The purpose of the current study is to focus on results related to the method of measuring lesion size called quantitative endoscopy (QE). The design includes a review of a total number of studies and then restricts analyses to the four clinics that enrolled more than four patients each for whom a baseline and 1‐year QE study was performed, comparing intra‐ and inter‐patient and clinic differences in Barrett's esophagus. Measurements include the number of total QEs and adverse events, changes in areas from baseline to 1 year and other intervals, classification of Barrett's lesion type with respect to patients, clinics, and treatment. A total of 309 QE studies were completed with no adverse events. Differences in surface area measurements over time for a particular patient are smaller than the differences for randomly selected patients. The complexity mix (as defined by the mix of circumferential, tongues, and islands) of the Barrett's lesions varied with different clinics. In conclusion, QE is an efficient, safe, and accurate way to measure the area of Barrett's lesions variation between different clinical sites may be attributable to a subtle type of selection bias at the individual clinics rather than to regional differences.