A Prospective Endoscopic Study of Cardial Intestinal Metaplasia

Abstract

The incidence of adenocarcinoma of gastric cardia has increased in the last decade in United States and Western Europe. Cardia intestinal metaplasia (CIM) could be an intermediate step in the cascade of events leading to cancer. Aim: To investigate the prevalence of CIM in patients undergoing upper gastro intestinal endoscopy in correlation with potential risk factors. Methods: 232 patients were prospectively evaluated as to age, sex, race, tobacco, alcohol intake, NSAIDs and GERD. During endoscopy, four biopsies were taken from antrum and corpus according to the Sydney System, including helicobacter pylori (Hp) assessment by Giemsa staining. Two specimens were obtain from the gastric cardia. Statistics: Chi-Square tests, Fisher's exact test and Crosstabulation. Results: CIM was found in 38 (16.4 %), dysplasia in 8 patients, 6 mild, 2 moderate, always associated with CIM (3.4%). No correlation was found between CIM and sex (F=16.7% vs M=16.1%, NS), race (caucasien: 16,9% vs african: 12.0%, NS), alcohol intake (8.5% vs 18.4%, NS), NSAIDs (18.0% vs 15.8%, NS) or gastritis (13.7% vs 15.4%, NS). CIM was not more frequently found in Hp+ (17.1%) than in Hp- subjects (16.4%) (p=0.09). Statistical analysis shows a significantly higher prevalence of CIM in correlation with age (56.7 vs 47.4 yr, p=0.002), tobacco (25.3% vs 12.1%, p=0.01). The prevalence of CIM significantly rose according to the Savary-Miller classification of esophagitis (no esophagitis: 7.0%, grade 1: 16.1%, grade 2: 13.9%, grade 3: 50.0%, grade 4: 50.0%, p=0.003). There is a statistical correlation between CIM and the presence of IM in gastric antrum (44.4% vs 13.7%, p=0.003) or in Barrett esophagus (66.7% vs 12.9%, p<0.001). Conclusions: This study shows a positive correlation between the presence of CIM and endoscopic features of GERD, and not with Hp prevalence. These results suggest a pathway, which may link GERD and the increasing incidence of cardial cancer in developed countries. These findings support that multiple biopsy specimens from the cardial mucosa should be obtained to detect early pathological changes in all patients with GERD. CIM also increases with age and smoking habits.