Endomicroscopy in Comparison with Acetic Acid Guided Endoscopy for the Detection of Barrett's Esophagus-A Prospective Randomized Cross Over Trial

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Introduction: Barrett's epithelium is often distributed in a patchy fashion within columnar lined lower esophagus (CLE). Acetic acid guided endoscopy (AAGE) allows targeting biopsies within CLE based on surface patterns whereas endomicroscopy (EM) allows targeting based on in vivo cellular architecture. Aim of the study was to prospectively compare the diagnostic yield for BE for the two methods. Methods: Consecutive patients with known non dysplastic BE with a length of at least 1 cm were included and randomly assigned to endomicroscopy or AAGE. PPI therapy in double standard dosage (esomeprazole) was continued for 6 months and patients were rescheduled for endoscopy with AAGE (Pentax Zoom endoscope EC 3870ZK; 2 ml acetic acid 2% per cm CLE length) or endomicroscopy (Pentax EC 3870 ZK) [cross over design]. Primary outcome analysis was the histological proof of Barrett's epithelium per targeted biopsied area and number of biopsies needed. Areas within CLE were judged during ongoing endoscopy for the presence of type III or IV staining pattern (Guelrud's classification) or the in vivo detection of goblet cells (Confocal Barrett's classification). Results: 26 patients (male: 19; mean length of BE 4.2 cm) were included. AAGE revealed Barrett's epithelium with a sensitivity of 89% and specificity of 100%, respectively. CE allowed in vivo identification of goblet cells and Barrett's epithelium could be proven in all cases in targeted biopsies (Sensitivity 100%, Specificity 100%) [p = ns]. Total number of biopsies per patient was significant lower using CE (1.2) compared to AAGE (5.2) [p = 0.045]. Conclusions: Acetic acid guided endoscopy and confocal laser endomicroscopy both facilitate the identification of Barrett's epithelium within CLE. However, in vivo histology during ongoing endoscopy using endomicroscopy can further significant reduce the number of biopsies needed diagnosing Barrett's esophagus.