Enhanced Magnification Directed Biopsies for Detection of Intestinal Metaplasia in Patients with GERD

Abstract

Background: The diagnosis of Barrett's esophagus (BE) requires histologic confirmation of specialized intestinal metaplasia (SIM) through biopsy, a technique prone to sampling error. A promising method to improve the yield of biopsy uses acetic acid with magnification endoscopy: Enhanced Magnification Endoscopy (EME). This technique identifies mucosal surface patterns and of these, pattern types III and IV have been associated with SIM. Methods: We conducted a prospective, randomized trial to evaluate EME directed biopsies and standard endoscopy with random biopsies in patients with symptoms of GERD. Patients in the standard endoscopy group with evidence of BE had 4 quadrant random biopsies taken every 2 cms. If there was no BE, 4 quadrant biopsies were taken at the SCJ. Patients in the EME group had the mucosa at the SCJ classified as Type I) round pits, Type II) reticular, III) villous or IV) ridged based on published criteria. In some cases, the visualized pattern did not fall into one of these categories and was labeled Type V. Biopsies were taken from each pattern type. Results: 93 patients enrolled (44 with EME, 49 with standard endoscopy). 36 (39%) had endoscopic evidence of BE (12 standard endoscopy, 24 EME). The yield of SIM using EME for each pattern type is shown (table). Of the 12 patients with apparent BE on standard endoscopy, random biopsies confirmed SIM on a per patient basis in 6 (50%) and in 6 (25%) for the 24 with EME directed biopsies. Overall, the prevalence of SIM was higher in the standard endoscopy group (50%) vs. EME (25%), but if pattern type III or IV were identified, EME confirmed SIM in 75% (6/8 patients). Patients without apparent BE (57) had SIM of the SCJ confirmed in 16% (6/37) with standard endoscopy and random biopsies compared with 5% (1/20) using magnification endoscopy. Conclusions: Random biopsies of endoscopically apparent BE yield SIM at slightly lower rates than targeted biopsies with EME in patients with pattern types III or IV. However, overall it appears that the yield of biopsy confirming SIM using these two techniques is similar. This calls into question the utility of this technique in reducing sampling error to identify SIM.