Esophageal Mucosa Of Patients Research Articles

Histological changes of the esophageal mucosa in patients with achalasia

Background. Morphological changes in the esophageal mucosa (EM) depend on the type of esophageal achalasia (ЕA). In types I and II of ЕA, morphological changes are subtle, but in types III and IV, dystrophic changes are clearly visible. ЕA can transform from one type to another. This mainly concerns the pathological transition from inflammation to fibrosis. The purpose is to investigate the histological and morphometric differences of the EM depending on the type of ЕA. Materials and methods. We studied 51 biopsy specimens of the EM in patients with ЕA. The distribution of biopsies for histo-morphometric characterisation of changes in the EM in ЕA was used according to the radiological classification of the Japanese Society of the Esophagus (2017). To study the general histological structure of the EM, biopsy sections of 5–7 μm thickness were cut using a rotary microtome RM60-ECA, stained with hematoxylin-­eosin according to the standard method, and staining for fibrosis was performed according to the Mallory-Slinchenko method. For morphometric study, the sections were photographed using a light microscope XSZ-21 (Ukraine) and measured with the Image J.45S software (USA). Results. In histological examination, the development of structural changes in the EM on the background of ЕA in 24.1 % of cases of type III was accompanied by migration of eosinophils into the lamina propria, and in 100 % — by epithelial atrophy. Dense lymphoplasmacytic infiltration was noted in all patients with types III and IV of ЕA, as well as in 93.3 % of patients with type II, whereas in type I of ЕA, this sign was diagnosed in 20 % of cases (p = 0.005 and p = 0.0001 compared with types II and III of ЕA). Ballooning degeneration was detected in 20 % of patients with EA type II, in 57.1 % with type III and in 100 % of patients with type IV. Fibrosis in the EM was observed only in ЕA type IV. Thickening of the basal layer of the squamous epithelium of the EM was noted in all patients with type IV ЕA and 86.2 % with type III ЕA, while in types I and II, it was observed in only 20 and 13.3 % of cases, respectively (p = 0.007 and p < 0.001 compared with type III ЕA). Expansion of the intercellular space was detected in 100 % of patients with types II, III and IV, and in only 40 % with type I (p = 0.009 and p = 0.0017 compared with types II and III ЕA). According to the morphometric study, the squamous epithelial height was largest in type IV ЕA — 343.40 μm versus 325.45 μm in type I ЕA (p = 0.028). The height of the basal layer was the lo­west in type II ЕA (about 40 µm) and the largest in type IV ЕA (about 50 µm) (p = 0.074). An increase in the intercellular space by 41.6 % was noted with the progression of ЕA (p = 0.001). The height of the papillae is the lowest in type II ЕA — 125.05 μm and the largest in type IV ЕA — 134.70 μm (p = 0.006). Conclusions. All types of AE are accompanied by esophagitis, histological examination of which revealed an increase in the height of the basal layer, papillae height, expansion of the intercellular space, balloon degeneration, fibrous changes in the lamina propria, lymphoplasmacytic and eosinophilic infiltration of the EM that progress depending on the type of ЕA. Morphometric studies of the EM in terms of increasing the height of the epithelium (p = 0.028), the height of the papillae (p = 0.006), the height of the basal layer (p = 0.074), and the expansion of the intercellular space (p = 0.001) allow to detect the type of ЕA.

Inquiring into the collusion between two-system diseases: Potential impact of hypertension over gastroesophageal reflux disease

Hypertension is a chronic condition that triggers inflammatory responses in the human body by activating immune cells and releasing pro-inflammatory cytokines. Recent studies have also revealed that gastroesophageal reflux disease (GERD) is associated with complex inflammatory changes in the esophagus, including immune aspects related to inflammatory pathways activation configuring it as a cytokine-dependent disease. In this hypothesis, we postulate that hypertension may act as an enhancer of esophageal inflammation, potentially exacerbating the damage to the esophageal mucosa in patients who share GERD and hypertension, regardless of their body mass index. We propose a new framework on the interaction between hypertension and GERD, emphasizing the importance of inflammation in the development and worsening of the disease. Understanding these mechanisms, this medical hypothesis endeavors to provide valuable insights to create novel perspectives of managing both conditions and to provide therapeutic approaches to control hypertension and reduce inflammation to the esophageal mucosa in GERD. Additional studies are needed to confirm these premises and elucidate the precise mechanisms involved in this complex interaction.

Diagnosis of Columnar Metaplasia of the Esophageal Mucosa in Patients with Complicated Gastroesophageal Reflux Disease

Aim: to improve methods of diagnostics of esophageal mucosal forms of metaplasia and dysplasia in patients with complicated forms of gastroesophageal reflux disease (GERD) using multidisciplinary approach.Material and methods. Overall, 131 patients aged 18 to 84 years (mean age — 55.8 ± 16.7 years) with confirmed diagnosis of GERD complicated by development of metaplasia of mucosa of distal esophagus were included in retroand prospective study. At the prehospital stage the patients' complaints were estimated, anamnesis was taken. At the first stage of the diagnostic program all patients underwent detailed esophagogastroduodenoscopy in high resolution with white light. The region of esophageal mucosa with signs of metaplasia and determination of its prevalence was examined and evaluated with special attention. Ultrashort segment was revealed in 26 patients, short segment — in 47 patients, long segment of mucosal metaplasia was revealed in 58 patients. Then to reveal the signs of dysplasia we used specifying endoscopic methods: the structure of pitted and microvascular pattern was estimated in narrow spectral mode using BING classification system. If an irregular type of metaplasized epithelium structure was detected in the process of BING assessment, the areas suspicious for dysplasia were marked, followed by aim forceps biopsy from them. The next stage was staining of the metaplasized segment with 1.5 % ethanic acid solution — acetowhitening. PREDICT classification system was used to evaluate the stained mucosal sections with metaplasia. Targeted forceps biopsy was performed from the altered areas that most quickly lost their coloring. The final stage of the diagnostic program in all patients was a forceps biopsy of the mucosa of the metaplasic segment according to the Seattle protocol, which requires increasing the number of fragments as the metaplasic segment lengthens in a “blind” biopsy. The biopsy material was stained with hematoxylin and eosin, and periodic acid Schiff reaction was performed in combination with alcyanine blue according to the standard technique.Results. Endoscopic examination in white light and evaluation of metaplasia extent revealed ultrashort segment (<1 cm) in 26/131 (19.9 %) patients; short segment (1–3 cm) — in 47/131 (35.9 %); long segment (> 3 cm) — in 58/131 (44.3 %) patients. Among the diagnostic techniques used, the BING and PREDICT classifications had the highest accuracy, sensitivity, and specificity (accuracy — 88.9 and 95.3 %, sensitivity — 90.5 and 91.3 %, and specificity — 86.7 and 100 %, respectively), which significantly exceeded the Seattle protocol also used in this work. The results showed a low level of specificity (31.2 %), accuracy (54.5 %), and sensitivity (76.8 %) of the Seattle protocol. The use of BING and PREDICT classifications provided marking of compromised zones, allowing targeted histological sampling.Conclusions. The original study demonstrated the greatest sensitivity, specificity, and accuracy of PREDICT and BING methods in the diagnosis of metaplasia with signs of dysplasia in patients with complicated GERD. It is also important that the use of BING and PREDICT classification systems allows to reduce the number of biopsy samples in comparison with their unreasonably large number according to the Seattle protocol, thereby reducing mucosal and submucosal trauma of the esophagus and the risk of complications.

Extracellular distribution of galectin-10 in the esophageal mucosa of patients with eosinophilic esophagitis.

Eosinophilic esophagitis is a T-cell-driven allergic condition hallmarked by eosinophil infiltration of the esophagus. Eosinophils exposed to proliferating T cells release galectin-10 and have T-cell suppressive function in vitro. The aims of this study were to evaluate if eosinophils co-localize with T cells and release galectin-10 in the esophagus of patients with eosinophilic esophagitis. Esophageal biopsies from 20 patients with eosinophilic esophagitis were stained for major basic protein, galectin-10, CD4, CD8, CD16, and CD81 and analyzed by immunofluorescence confocal microscopy before and after topical corticosteroid treatment. CD4+ T-cell numbers decreased in the esophageal mucosa of responders to treatment but not in the non-responders. Suppressive (CD16+) eosinophils were present in the esophageal mucosa of patients with active disease and decreased after successful treatment. Unexpectedly, eosinophils and T cells were not in direct contact with each other. Instead, the esophageal eosinophils released large amounts of galectin-10-containing extracellular vesicles and featured cytoplasmic projections that contained galectin-10, both of which disappeared from the esophagus of the responders but remained in the non-responders. To conclude, the presence of CD16+ eosinophils together with the massive release of galectin-10-containing extracellular vesicles in the esophageal mucosa might indicate that eosinophils exert T-cell suppression in eosinophilic esophagitis.

Analysis of local expression of inflammatory cytokines genes in patients with gastroesophageal reflux disease and its association with types and number of gastroesophageal refluxes

The aim of the study was to evaluate gene expression of proinflammatory cytokines in esophageal mucosa in patients with erosive esophagitis (EE) and non-erosive form (NERD) of gastroesophageal reflux disease (GERD) and perform correlation analysis between the genes expression and types and number of gastroesophageal refluxes. Methods. This was a single-center prospective study. Esophageal mucosa samples were taken from lower part of the esophagus during endoscopy. Expression of IL-1b, IL-10, IL-18, TNFA, TLR4, GATA3, CD68 and beta-2 macroglobulin genes was assessed with ImmunoQuantex assays. Multichannel intraluminal esophageal pH-impedance studies were performed with Ohmega recorder and 2pH-6impedance catheters. Results. Data of 60 patients (females - 34; mean age (M±SD) 54.6 years, 20 - with erosive esophagitis) were available for the analysis. In those with EE, there was higher expression of IL-18 (5.89±0.4 vs 5.28±1.1, p=0.04), GATA3 (2.92±0.86 vs 2.23±0.96, p=0.03) genes, and inflammatory index (92.12±32.41% vs 70.1±30.8%, p=0.02) compared to NERD. Direct correlation was found between acid exposure time and expression of IL-1b (Spearman rank R = 0.29), IL-18 (R=0.31), TNFA (R=0.35), GATA3 (R=0.34), TLR4 (R=0.29), CD68 (R=0.37) genes and inflammatory index (R=0.3). Indirect correlation was revealed between mean рН and expressions of IL-18 (R= -0.28), TNFA (R= -0.33), GATA3 (R= -0.28), TLR4 (R= -0.28), CD68 (R= -0.39) genes and inflammatory index (R= -0.17). No correlation was found between the genes’ expression and number of gastroesophageal refluxes. Conclusions: Expression of proinflammatory cytokines’ genes differ in patients with EE and NERD. There is a correlation between expression of studied genes and esophageal acidity.

149. LOCAL INFLAMMATORY RESPONSE TO GASTROESOPHAGEAL REFLUX: ASSOCIATION OF GENE EXPRESSION OF INFLAMMATORY CYTOKINES WITH MULTICHANNEL INTRALUMINAL PH-IMPEDANCE DATA

Abstract Expression of inflammatory cytokines’ genes may take part in pathophysiology of different forms of gastroesophageal reflux disease (GERD). Aim: to explore the expression of inflammatory cytokines’ genes in esophageal mucosa in patients with erosive esophagitis and non-erosive forms of gastroesophageal reflux disease and its association with data of esophageal multichannel intraluminal pH-impedance measurements. This was a single-center prospective study. Esophageal mucosa samples were taken from lower part of the esophagus during endoscopy. Expression of IL-1β, IL-10, IL-18, TNFA, TLR4, GATA3, CD68, beta-2 macroglobulin genes in esophageal mucosa was assessed with ImmunoQuantex assays. Multichannel intraluminal esophageal pH-impedance (MII-pH) studies performed to all the participants. Diagnosis of GERD was confirmed by the results of MII-pH data. Patients were allocated to erosive esophagitis (EE) or non-erosive GERD groups (NERD). Non-symptomatic subjects with normal endoscopy and MII-pH results served as a control. Spearman rank correlation was used to asses association of genes expression and results of MII-pH. Data of 60 patients with GERD and 10 subjects of the control group were available for the analysis. Higher expression of IL-18 (5.89 ± 0.4 vs 5.28 ± 1.1, p = 0.04) and GATA3 (2.92 ± 0.86 vs 2.23 ± 0.96, p = 0.03) genes was found in EE group compared to NERD. Expression of IL-1β, IL-18, TNFA, and TLR4 genes was lower (P < 0.05) in the control group compared to EE and NERD. Esophageal acid exposure correlated with the expression of IL-1β (R = 0.29), IL-18 (R = 0.31), TNFA (R = 0.35), GATA3 (R = 0.34), TLR4 (R = 0.29), CD68 (R = 0.37) genes. Mean esophageal рН correlated inversely with the expressions of IL-18, TNFA, GATA3, TLR4, CD68 genes. In patients with erosive esophagitis, local expression of interleukin 18 and GATA3 transcription factor genes was higher compared to subjects with non-erosive form of gastroesophageal reflux disease. Esophageal acid exposure correlated directly with expression of IL-1β, IL-18, TNFA, TLR4, CD68 and B2M genes. Inverse correlation revealed between expression of IL-18, TNFA, GATA3, TLR4 CD68 genes and mean esophageal pH.

Local inflammatory response to gastroesophageal reflux: Association of gene expression of inflammatory cytokines with esophageal multichannel intraluminal impedance-pH data.

BACKGROUNDGene expression of inflammatory cytokines may take part in the pathophysiology of different forms of gastroesophageal reflux disease (GERD).AIMTo explore gene expression of inflammatory cytokines in esophageal mucosa in patients with erosive esophagitis (EE) and non-erosive forms of GERD (NERD) and its association with data of esophageal multichannel intraluminal impedance-pH (MII-pH) measurements.METHODSThis was a single-center prospective study. Esophageal mucosa samples were taken from the lower part of the esophagus during endoscopy. Expression of interleukin (IL)-1β, IL-10, IL-18, tumor necrosis factor α (TNFA), toll-like receptor 4 (TLR4), GATA binding protein 3 (GATA3), differentiation cluster 68 (CD68) and β-2 microglobulin genes in esophageal mucosa was assessed with ImmunoQuantex assays. MII-pH measurements were performed on all the participants. Diagnosis of GERD was confirmed by the results of the MII-pH data. Based on the endoscopy, patients were allocated to the groups of EE and NERD. The control group consisted of non-symptomatic subjects with normal endoscopy and MII-pH results. We used nonparametric statistics to compare the differences between the groups. Association of expression of the mentioned genes with the results of the MII-pH data was assessed with Spearman’s rank method.RESULTSData from 60 patients with GERD and 10 subjects of the control group were available for the analysis. Higher expression of IL-18 (5.89 ± 0.4 vs 5.28 ± 1.1, P = 0.04) and GATA3 (2.92 ± 0.86 vs 2.23 ± 0.96, P = 0.03) was found in the EE group compared to NERD. Expression of IL-1β, IL-18, TNFA, and TLR4 was lower (P < 0.05) in the control group compared to EE and NERD. Esophageal acid exposure correlated with the expression of IL-1β (Spearman’s rank r = 0.29), IL-18 (r = 0.31), TNFA (r = 0.35), GATA3 (r = 0.34), TLR4 (r = 0.29), and CD68 (r = 0.37). Mean esophageal рН correlated inversely with the expression of IL-18, TNFA, GATA3, TLR4, and CD68. No association of gene expression with the number of gastroesophageal refluxes was found.CONCLUSIONIn patients with EE, local expression of IL-18 and GATA3 was higher compared to subjects with NERD. Esophageal acid exposure correlated directly with expression of IL-1β, IL-18, TNFA, TLR4, CD68, and β-2 microglobulin genes. Inverse correlation was revealed between expression of IL-18, TNFA, GATA3, TLR4, and CD68 and mean esophageal pH.

Molecules involved in the development of Barrett's esophagus phenotype in chronic eosinophilic esophagitis.

This paper aims to investigate the molecules involved in development of Barrett's esophagus (BE) in human eosinophilic esophagitis (EoE). Histopathological, immunohistochemical, real-time PCR Immuno blot, and ELISA analyses are performed to identify the signature genes and proteins involved in the progression of BE in EoE. We detected characteristic features of BE like intermediate columnar-type epithelial cells, induced BE signature genes like ErbB3, CDX1, ErbB2IP in the esophageal mucosa of patients with EoE. In addition, we had observed several BE-associated proteins such as TFF3, p53 and the progression markers like EGFR, p16, MICA, MICB, and MHC molecules in esophageal biopsies of patients with chronic EoE. Interestingly, we also detected mucin-producing columnar cells and MUC-2, MUC-4, and MUC5AC genes and proteins along with induced IL-9 in patients with chronic EoE. A strong correlation of IL-9 with mucin genes is observed that implicated a possible role for IL-9 in the transformation of esophageal squamous epithelial cells to columnar epithelial cells in patients with EoE. These findings indicate that IL-9 may have an important role in BE development in patients with chronic EoE. We also discovered that IL-9 stimulates mucin-producing and barrier cell transcripts and proteins such CK8/18, GATA4, SOX9, TFF1, MUC5AC, and tight junction proteins in primary esophageal epithelial cells when exposed to IL-9. Taken together, these findings provide evidence that indeed IL-9 has a role in the initiation and progression of BE characteristics like development of mucin-producing columnar epithelial cells in patients with chronic EoE.NEW & NOTEWORTHY Intermediate columnar-type epithelial cells are observed in biopsies of patients with EoE. Induced BE signature genes (CK8/18, CDX1 GATA4, SOX9, and Occludin) were observed in patients with chronic EoE. Induction of IL-9 and its correlation with eosinophils mucin-producing genes and proteins was observed in patients with EoE. Induced IL-9 may be responsible for the development of BE in patients with chronic EoE.

Gene expression profiling of inflammatory cytokines in esophageal biopsies of different phenotypes of gastroesophageal reflux disease: a cross-sectional study

BackgroundThe clinical endoscopic phenotypes of gastroesophageal reflux disease (GERD) are classified as Barrett's esophagus (BE), erosive esophagitis (EE) and non-erosive gastroesophageal reflux disease (NERD). NERD is subclassified as abnormal acid exposure (AAE) and normal acid exposure (NAE) based on pH monitoring study results. The aim of this study was to characterize genes involved in the pathophysiology and immune response of GERD.MethodsThis is an observational and cross-sectional study. All patients with BE, EE, AAE, and NAE and a control group were subjected to superior endoscopy (with biopsies of esophageal mucosa). Relative mRNA quantification of cytokine and target genes was conducted by quantitative Polymerase Chain Reaction (RT-qPCR). Changes in the expression of genes associated with inflammation were assessed for each disease phenotype. Statistical analysis of differential gene expression was performed using the Mann–Whitney U non-parametric test. A p value < 0.05 was considered significant.ResultsA total of 82 patients were included and were divided into the following groups: Group BE, 16 (19.51%); Group EE, 23 (28.04%); Group AAE, 13 (15.86%); NAE 13 (15.86%); and Control Group, 17 (20.73%). Compared with the control group, patients with BE exhibited increased IL-8 expression (p < 0.05) and increased levels of IL-10, MMP-3, and MMP-9. Patients with EE exhibited increased levels of IL-1B, IL-6 and IL-10 (p < 0.05), and patients with AAE exhibited increased expression of IL-1B, IL-6, IFN-γ and TNF-α (p < 0.05). AAE exhibited increased IL-1B and TNF-α expression compared with NAE (p < 0.05).ConclusionThis study demonstrates the differential expression of mediators of inflammation in the esophageal mucosa of patients with different GERD endoscopic phenotypes. IL-1B and TNF-α could be useful to differentially diagnose AAE and NAE in the non-erosive phenotype using endoscopic biopsies.

Heartburn sensation in nonerosive reflux disease: pattern of superficial sensory nerves expressing TRPV1 and epithelial cells expressing ASIC3 receptors.

The underlying causes of heartburn, characteristic symptom of gastroesophageal reflux disease (GERD), remain incompletely understood. Superficial afferent innervation of the esophageal mucosa in nonerosive reflux disease (NERD) may drive nociceptive reflux perception, but its acid-sensing role has not yet been established. Transient receptor potential vanilloid subfamily member-1 (TRPV1), transient receptor potential melastatin 8 (TRPM8), and acid-sensing ion channel 3 (ASIC3) are regulators of sensory nerve activity and could be important reflux-sensing receptors within the esophageal mucosa. We characterized TRPV1, TRPM8, and ASIC3 expression in esophageal mucosa of patients with GERD. We studied 10 patients with NERD, 10 with erosive reflux disease (ERD), 7 with functional heartburn (FH), and 8 with Barrett's esophagus (BE). Biopsies obtained from the distal esophageal mucosa were costained with TRPV1, TRPM8, or ASIC3, and CGRP, CD45, or E-cadherin. RNA expression of TRPV1, TRPM8, and ASIC3 was assessed using qPCR. Patients with NERD had significantly increased expression of TRPV1 on superficial sensory nerves compared with ERD (P = 0.028) or BE (P = 0.017). Deep intrapapillary nerve endings did not express TRPV1 in all phenotypes studied. ASIC3 was exclusively expressed on epithelial cells most significantly in patients with NERD and ERD (P ≤0.0001). TRPM8 was expressed on submucosal CD45+ leukocytes. Superficial localization of TRPV1-immunoreactive nerves in NERD, and increased ASIC3 coexpression on epithelial cells in NERD and ERD, suggests a mechanism for heartburn sensation. Esophageal epithelial cells may play a sensory role in acid reflux perception and act interdependently with TRPV1-expressing mucosal nerves to augment hypersensitivity in patients with NERD, raising the enticing possibility of topical antagonists for these ion channels as a therapeutic option.NEW & NOTEWORTHY We demonstrate for the first time that increased pain perception in patients with nonerosive reflux disease likely results from expression of acid-sensitive channels on superficial mucosal afferents and esophageal epithelial cells, raising the potential for topical therapy.

THE ROLE OF QUALITY OF LIFE IN MELATONIN CONTENT AS A REGULATOR OF DEFENSE AND AGGRESSION FACTORS IN GASTROESOPHAGEAL REFLUX DISEASE PATIENTS WITH SLEEP APNEA SYNDROME

The aim of the study: to study the effect of the quality of life on the melatonin content, and at the same time to assess the state of the factors of aggression and protection of the esophageal mucosa in patients with GERD without comorbidities and with concomitant obstructive sleep apnea/hypopnea syndrome (OSAHS).&#x0D; Methods. 45 patients were taken for the study. 23 of them had GERD concomitant COPD, 22 were with isolated GERD with a non-erosive form.&#x0D; Melatonin levels were determined using the enzyme immunoassay method (ELIZA). Quality of life was assessed using the SF-36 questionnaire. Antioxidant protection of the mucous membrane (protection factor) – was assessed by the activity of superoxide dismutase (SOD). SOD activity in blood serum was determined by calorimetric method. Determination of the DC level was carried out in the blood by the spectrofluorimetric method.&#x0D; Results. The study showed that in patients with GERD with concomitant COPD, there is a significant decrease in the indicators of antioxidant activity and melatonin, both with indicators from the control group and with indicators of patients with GERD without comorbidity.&#x0D; At the same time, in patients with GERD without comorbidities, an increase in the level of DC was observed in comparison with the control group and patients with GERD with concomitant pathology and acidity of gastric juice.&#x0D; When analyzing the indicators of QOL in patients with GERD with concomitant pathology, there is a significantly more pronounced decrease in mental health, role emotional functioning and vitality.&#x0D; Conclusions. It has been established that in patients with GERD in the stage of exacerbation of the disease, there is a statistically significant decrease in QOL indicators with a high degree of reliability, manifesting itself in patients without combined pathology in the spectrum of indicators of the physical component of health, and in patients with GERD with concomitant obstructive sleep syndrome – in the spectrum of the psychological component quality of life.&#x0D; It has been shown that with a decrease in QOL in patients with GERD, the level of melatonin decreases, the decrease in which more clearly increases in patients with concomitant obstructive sleep apnea.&#x0D; Simultaneously with a drop in the level of melatonin in patients with GERD without associated pathology, the aggression factor increases with a high degree of certainty - that is, a decrease in the pH of gastric juice and an increase in the content of DC, while in patients with GERD with concomitant sleep apnea syndrome, the factor decreases with a high degree of certainty. Protection of the esophageal mucosa – (that is, a decrease in SOD activity), which must be taken into account when treating this category of patients.

Histopathological Analysis of Esophageal Mucosa in Patients with Achalasia.

Background/AimsAchalasia is an esophageal motor disorder that leads to functional esophageal obstruction. Food stasis and bacterial fermentation can predispose an individual to esophageal mucosal inflammation, causing multifocal dysplasia and increasing the risk of developing esophageal squamous cell carcinoma. We aimed to evaluate esophageal mucosal alterations in achalasia patients and determine clinical factors associated with the histopathological findings.MethodsFrom 2009 to 2013, we obtained endoscopic biopsies from the lower and middle esophagus of 22 patients with achalasia and 17 controls. Patients’ clinical data and histological severity of esophagitis were retrospectively analyzed. Additionally, immunohistochemical staining for CD3, CD20, Ki-67, and p53 was conducted.ResultsThe median age of achalasia patients was 49.5 years (range, 27 to 82 years), and there were nine males (40.9%). The median symptom duration was 5.8 years (range, 1 to 33.5 years), and 10 patients (45%) underwent previous treatment (nine, balloon dilation; one, botulinum toxin injection). Achalasia patients had significantly more severe esophagitis than did controls (p=0.001, lower esophagus; p=0.008, middle esophagus), and the number of CD3-positive lymphocytes exceeded that of CD20-positive lymphocytes (p<0.001). Achalasia patients also had a higher esophageal Ki-67 proliferation index (p=0.048). Although statistically nonsignificant, p53 expression was only observed in achalasia patients. There was no association between the histological severity of esophagitis and other clinicopathological findings.ConclusionsAchalasia patients showed significantly severe histological esophagitis and a high Ki-67 proliferation index, indicating an increased risk of neoplastic progression. Therefore, careful endoscopic inspection is necessary for the early detection of superficial neoplasia in these patients. (Gut Liver 2021;15-722)

PECULIARITIES OF STATE OF PROTECTION AND AGGRESSION FACTORS IN PATIENTS WITH DIABETES MELLITUS TYPE II AND GASTROESOPHAGEAL REFLUX DISEASE

Diabetes mellitus is one of the most serious problems of the clinical medicine. This is determined by the fact that it is followed by multisystemic affects, as well as complications on the side of other organs and systems, among which a special place is occupied by gastroesophageal reflux disease. As for the combination and mutual influence of diabetes mellitus and gastroesophageal reflux disease, this issue has not been studied yet, the data of modern literature are not complete and quite contradictory. The aim of the study: to investigate the state of the factors of aggression and protection of the oesophageal mucosa in patients with diabetes mellitus type II with concomitant gastroesophageal reflux disease without associated pathology. Method. There were two groups of patients under observation. The first group included 45 patients with diabetes mellitus type II with concomitant gastroesophageal reflux disease (26 men and 19 women). The second group included 38 patients with gastroesophageal reflux disease without associated pathology – 20 men and 18 women. By sex, age, body weight, Helicobacter pylori infection, smoking and alcohol consumption, both groups were comparable. The surveillance program included determining the compensation ratio of carbohydrate metabolism and the state of the factor. The antioxidant protection factor was assessed by the level of catalase activity in the blood serum, as well as by the diameter of the celiac trunk and the blood flow velocity in it. Statistical processing of the obtained data was carried out with the aid of the program WINDOWS STATISTIKA 6.0. For all types of analysis, differences were considered statistically significant with p&lt;0.05. Results. During the study, we found that in patients with diabetes mellitus type II with concomitant gastroesophageal reflux disease, as well as in patients with gastroesophageal reflux disease without associated pathology, the level of pH-metry was reduced, but with varying measures of confidence. At the same time, we found that patients with GERD without associated pathology had a decrease in the blood flow velocity in the celiac trunk. Concurrently, we ascertained that the decrease in the blood flow velocity in patients of both groups reduced the diameter of the celiac trunk. Conclusions. In patients with diabetes mellitus type II, concomitant gastroesophageal reflux disease has a subtle clinical presentation that is affected by a significant decline in mucosal sealing protection factors. In patients with GERD without associated pathology, typical clinical manifestations, accompanied by inflammation, acid regurgitation and dyspepsia, are more vivid.

The Significance of a Pale Area Via Flexible Spectral Imaging Color Enhancement in the Diagnosis of Esophageal Precancerous Lesions and Early-stage Squamous Cancer.

Goals:The main aim of this study was to investigate the significance of a pale area via flexible spectral imaging color enhancement (FICE) in the diagnosis of esophageal dysplasia and cancer.Background:The early diagnosis of esophageal squamous cancer is challenging, and the indication of Lugol’s chromoendoscopy has not yet been well established.Study:The esophageal mucosa of patients at our endoscopic center were sequentially evaluated with white-light endoscopy and FICE during insertion of the endoscope, followed by staining with Lugol’s solution during withdrawal. Patients were divided into 2 groups depending on whether esophageal leukoplakia was detected by white-light endoscopy and 2 groups depending on whether a pale area was detected by FICE. We compared cases of patients with abnormal iodine staining, and cases of dysplasia or cancer in esophageal leukoplakia—or pale area—positive and negative groups.Results:Cases of abnormal staining in the esophageal leukoplakia—or pale area—positive group were far more numerous than cases without esophageal leukoplakia or pale area, respectively (P=0.000). Cases of esophageal dysplasia and cancer in the esophageal leukoplakia—or pale area—positive group were far more numerous than cases without esophageal leukoplakia or pale area, respectively (P=0.000).Conclusions:Iodine staining should be performed in patients with esophageal leukoplakia or pale areas. Esophageal dysplasia and early-stage cancer were more easily detected in those with esophageal leukoplakia or pale areas.

Histologic diagnosis and grading of esophageal acute graft-versus-host disease.

Acute intestinal graft-versus-host disease (GvHD) is a serious threat after allogeneic hematopoietic stem cell transplantation (alloHSCT). Although criteria for the histological diagnosis and grading of GvHD are well established for most parts of the gastrointestinal tract, evidence-based criteria have not yet been defined for the esophagus. Here, we evaluated esophageal biopsies obtained from 51 patients who underwent alloHSCT and compared the findings with those within the stomach and duodenum. In 32 of 51 biopsy samples of the esophagus, we identified a continuum of histological features of acute GvHD, ranging from vacuolar degeneration and single-cell apoptosis to the formation of clefts and mucosa denudation in advanced cases. These findings correlated with GvHD involving the stomach and duodenum and the clinical manifestations of GvHD in other organs. We therefore conclude that acute GvHD and esophageal GvHD can be diagnosed and graded histologically. Our findings may help to establish the histological diagnosis of acute GvHD using endoscopic biopsies from the esophagus and to explain the alterations observed in the esophageal mucosa in patients after alloHSCT.

КОЛЛАГЕН IV ТИПА КАК БИОМАРКЕР ПОВРЕЖДЕНИЯ СЛИЗИСТОЙ ОБОЛОЧКИ ПИЩЕВОДА У ПАЦИЕНТОВ С ГАСТРОЭЗОФАГЕАЛЬНОЙ РЕФЛЮКСНОЙ БОЛЕЗНЬЮ И СИНДРОМОМ ОБСТРУКТИВНОГО АПНОЭ/ГИПОПНОЭ СНА

Background. Obstructive sleep apnea/hypopnea syndrome (OSAHS) seems to have negative effect on the state of&nbsp;patients with gastroesophageal reflux disease (GERD).Aim: to evaluate plasma levels of type IV collagen as a potential biomarker of esophageal mucosa damage in&nbsp;patients with GERD accompanied by OSAHS.Material and methods. A total of 120 patients were examined: 29 persons with GERD, 35 – with GERD and OSAHS,&nbsp;30 – with OSAHS, 26 persons – the comparison group. Respiratory monitoring and esophagogastroduodenoscopy&nbsp;were performed. Plasma level of type IV collagen was evaluated in 80 patients by using enzyme-linked immunosorbent&nbsp;assay.Results. Patients with erosive esophagitis had higher plasma levels of type IV collagen then patients with nonerosive&nbsp;esophagitis and those of the comparison group. Patients with GERD accompanied by OSAHS had higher plasma levels&nbsp;of type IV collagen in comparison with those who had GERD without OSAHS.Conclusions. OSAHS has negative impact on the state of esophageal mucosa in patients with GERD which leads&nbsp;to an increase in type IV collagen concentration in plasma.

ЭКСПРЕССИЯ Е-КАДГЕРИНА В СЛИЗИСТОЙ ОБОЛОЧКЕ ПИЩЕВОДА У ПАЦИЕНТОВ С ГАСТРОЭЗОФАГЕАЛЬНОЙ РЕФЛЮКСНОЙ БОЛЕЗНЬЮ И/ИЛИ СИНДРОМОМ ОБСТРУКТИВНОГО АПНОЭ/ГИПОПНОЭ СНА

Background. Obstructive sleep apnea/hypopnea syndrome (OSAHS) seems to have a negative impact on the state of esophageal mucosa in patients with GERD, therefore it is significant to evaluate the structure of esophageal epithelium in patients with GERD and OSAHS. Objective – to evaluate E-cadherin expression in the epithelium of the lower third of the esophagus in patients with GERD and/or OSAHS. Materials and methods. 143 examined patients have undergone esophagogastroduodenoscopy with the biopsy of the lower third of the esophagus as well as respiratory monitoring. The patients were divided into 4 groups: group 1 – patients with GERD (n=35), group 2 – patients with GERD and OSAHS (n=40), group 3 – with OSAHS (n=38), group 4 – control group (n=30). There have been performed the identification of plasma concentration of N-terminal E-cadherin fragment and evaluation of E-cadherin expression in the epithelium of the lower third of the esophagus. Results. The patients with GERD and OSAHS had statistically significant higher plasma concentration of N-terminal E-cadherin fragment in comparison to other groups. E-cadherin expression in the epithelium was statistically significantly lower in all studied groups in contrast to the control group. There has been revealed a negative correlation between plasma concentration of N-terminal E-cadherin fragment and E-cadherin expression in the epithelium as well as between apnea/hypopnea index and E-cadherin expression. Conclusion. The patients with GERD and OSAHS are characterized by low E-cadherin expression in the epithelium of the lower third of the esophagus on the background of high plasma concentration of N-terminal E-cadherin fragment.

Germination of pollen grains in the oesophagus of individuals with eosinophilic oesophagitis.

Eosinophilic oesophagitis (EoE) is characterized by oesophageal dysfunction and, histologically, by eosinophilic inflammation. There is no a clear aetiologic treatment. EoE exacerbations are often seasonal. We hypothesized that the inflammatory response of the oesophageal mucosa in patients with high levels of antibodies to pollen allergens and worsened seasonal EoE might be due to swallowing airborne pollen and the intrusion into the oesophageal mucosa of pollen allergens and pollen tubes, which encounter a pH and humidity resembling the stigma at pollination. The aim of our study was to demonstrate the possible pathogenic role of environmental allergens in EoE through molecular and anatomopathological studies METHODS: One hundred and twenty-nine patients with EoE were tested for environmental and food allergens. Component resolved diagnosis (CRD), histological and botanical analysis was performed. Microscopic examination of oesophageal biopsies of 129 adults patients with EoE, 82 of them with seasonal exacerbation, and 100 controls, with gastroesophageal reflux without eosinophilic infiltrate, were made to verify the presence of callose (polysaccharide abundant in pollen tubes but absent in animal tissues) in the oesophagus. Component resolved diagnosis detected pollen allergens in 87.6% of patients with EoE. The predominant allergens were group 1 grass (55%), Art v 3 (11.3%) and lipid transfer proteins (LTPs) (19.4%) of common Mediterranean foods such as peach, hazelnuts, walnuts and wheat. Callose from pollen tubes was found in 65.6% of biopsies. Alteration of the mucosal barrier in EoE might cause the penetration of pollen grains into the oesophageal tissues. In EoE patients, anatomopathological studies searching for intrusion to plant foods and pollen, and specific-guided diet and immunotherapy after plant structures detection in biopsies, might be effective. It is possible to see the intrusion into animal tissues (oesophagus mucosa) of plant structures (pollen grains or pollen tubes) using an adecuate histologic botanical analysis. Molecular and anatomopathological studies can help to demonstrate a possible pathogenic role of environmental allergens in EoE.

A Rare Case of Coincident Barrettʼs Esophagus in Untreated Achalasia

Achalasia is characterized by failure of the lower esophageal sphincter (LES) to relax, with high basal LES pressure as well as failure of esophageal peristalsis. The disease manifests with primary symptoms of dysphagia and regurgitation. In contrast, Barrett's esophagus is linked to chronic gastroesophageal reflux disease (GERD) that results from chronic acid exposure related to excessive relaxation of the LES. This makes coexistence of conditions unusual. We report a case in which achalasia and Barrett's esophagus were diagnosed prior to treatment for achalasia. A 31-year-old male with a five-year history of GERD presented for evaluation of progressively worsening symptoms. Reflux symptoms had increased in frequency with several episodes of vomiting. Lifestyle modifications were recommended and he was started on daily omeprazole. One year later, he continued to complain of reflux symptoms, though he had noted some improvement. He had difficulty swallowing, with regurgitation of undigested food. A barium esophagram suggested achalasia. Esophagogastroduodenoscopy demonstrated narrowing of the gastroesophageal junction with a dilated esophagus, as well as a short tongue of salmon-colored mucosa (Prague classification C0M1). Histology demonstrated intestinal metaplasia without dysplasia. High-resolution esophageal manometry demonstrated a pattern consistent with type II achalasia. Laparoscopic Heller's myotomy was recommended, but the patient declined intervention. He was treated with submucosal injection of botulinum toxin with temporary symptom relief. Barrett's esophagus and achalasia do not typically co-exist, as they result from opposing dysfunctions of the LES. When achalasia is treated, excess acid reflux may occur from the resulting laxity of the LES, eventually leading to Barrett's esophagus in some patients. However, the diagnosis of both conditions in an individual patient prior to surgical or endoscopic interventions is exceedingly rare. This case reinforces the importance of careful inspection of the distal esophageal mucosa in patients with achalasia, as a patient with Barrett's esophagus at baseline may be at increased risk of progression of the Barrett's segment following therapeutic interventions.

MicroRNA-130a is highly expressed in the esophageal mucosa of achalasia patients.

Esophageal achalasia is considered as a risk factor of esophageal cancer. The etiologies of esophageal achalasia remain unknown. Peroral endoscopic myotomy (POEM) has recently been established as a minimally invasive method with high curability. The aims of the present study were to identify the microRNAs (miRs) specific to esophageal achalasia, to determine their potential target genes and to assess their alteration following POEM. RNA was extracted from biopsy samples from middle esophageal mucosa and analyzed using a microarray. Differentially expressed miRs in achalasia patients compared with control samples were identified and analyzed using reverse transcription-quantitative polymerase chain reaction (RT-qPCR). Correlations between specific miR expression levels and the patients' clinical background were also investigated. In addition, alterations of selected miR expression levels before and after POEM were analyzed. The results of RT-qPCR analysis demonstrated that the miR-130a expression levels were significantly higher in patients with achalasia (P<0.0001). In addition, miR-130a expression was significantly correlated with male sex and smoking history in patients with achalasia. However, no significant change in miR-130a expression was observed between before and after POEM. In conclusion, miR-130a is highly expressed in the esophageal mucosa of patients with achalasia and may be a biomarker of esophageal achalasia.