Presence Of Columnar-lined Esophagus Research Articles

Presence of columnar-lined esophagus is negatively associated with the presence of esophageal varices in Japanese alcoholic men

AIMTo determine whether the presence of columnar-lined esophagus (CLE) is associated with the presence of esophageal varices (EVs) in male Japanese alcoholics.METHODSThe subjects were 1614 Japanese alcohol-dependent men (≥ 40 years of age) who had undergone upper gastrointestinal endoscopic screening. Digitalized records of high-quality endoscopic images that included the squamocolumnar junction and esophagogastric junction were retrospectively jointly reviewed by four expert endoscopists for the purpose of diagnosing CLE. The authors investigated whether and to what extent there were associations between the presence of CLE and the presence of EVs, especially in the group with liver cirrhosis (LC).RESULTSCLE ≥ 5 mm in length was found in 355 subjects (≥ 30 mm in 6 of them), LC without EVs in 152 subjects, LC with EVs in 174 subjects, and EVs without LC in 6 subjects. Advanced EVs, i.e., nodular, large or coiled forms, red color sign, or post-treatment, were found in 88 subjects. The incidence of CLE ≥ 5 mm decreased in the following order (P < 0.0001): 23.3% in the group without EVs, 17.4% in the group with small and straight EVs, and 5.7% in the group with advanced EVs. The multivariate ORs (95%CI) for EVs and advanced EVs in the group with LC were lower when CLE ≥ 5mm was present [0.46 (0.23-0.93) and 0.24 (0.08-0.74), respectively, vs 0-4 mm CLE].CONCLUSIONThe presence of CLE in male Japanese alcoholics was negatively associated with the presence of EVs.

Histologic Features Associated With Columnar-lined Esophagus in Distal Esophageal and Gastroesophageal Junction (GEJ) Biopsies From GERD Patients: A Community-based Population Study.

There are inherent problems with the endoscopic and pathologic criteria for columnar-lined esophagus (CLE). Furthermore, the clinical and biological significance of an irregular squamocolumnar junction (SCJ) is unclear. The aim of this study was to evaluate the association between histologic features in SCJ biopsies and CLE and to gain insight into the significance of an irregular SCJ. The study was a cross-sectional analysis of 2176 mucosal biopsies of the SCJ from 544 patients in a large prospective community clinic-based study of gastroesophageal reflux disease in Washington State. Biopsy samples were evaluated blindly for a wide variety of histologic features, such as the presence and type of mucosal glands, submucosal glands and ducts, goblet cells, multilayered epithelium (ME), inflammation, and buried columnar epithelium. Histologic findings were correlated with the endoscopic findings (normal Z-line, irregular Z-line, or CLE) and evaluated by logistic regression and receiver operating characteristic analysis.Five histologic features were associated with CLE: pure mucous glands, ME, presence of goblet cells, ≥50% of crypts with goblet cells, and buried columnar epithelium. Pure oxyntic glands were inversely associated with CLE. The features most strongly related to CLE included biopsies with ≥50% of crypts with goblet cells, ME, and mucosal gland type (area under the curve=0.71; 95% confidence interval=0.66-0.76). Patients with an irregular Z-line were histologically similar to those with CLE. Certain histologic features in biopsies of the SCJ are associated with the presence of CLE. Irregularity of the Z-line is probably indicative of ultrashort segment CLE, instead of being a potential variation of normal.

Columnar-lined Esophagus: Its Prevalence and Predictors in Patients With Gastroesophageal Reflux Disease (Am J Gastroenterol 2012;107:1655-1661)

The prevalence of Barrett's esophagus has varied based on the study population diversity and the definition of Barrett's esophagus used. Because intestinal metaplasia in the distal esophagus predisposes to esophageal adenocarcinoma, Barrett's esophagus is defined as a condition in which normal stratified squamous epithelium is replaced by metaplastic columnar epithelium in the distal esophagus with histopathological evidence of intestinal metaplasia.1 However in other areas (UK and Asia), Barrett's esophagus is diagnosed solely based on the presence of columnar-lined esophagus (CLE) on endoscopy without the need to document intestinal metaplasia.2,3 This definition has been supported by some previous studies suggesting comparable cancer risk among those with CLE with and without intestinal metaplasia, and sampling error to identify goblet cells.4,5 Recently, Balasubramanian et al6 conducted a prospective study on 1,058 subjects with gastroesophageal reflux disease (GERD) to evaluate the prevalence and predictors of CLE. In this study, the prevalence of CLE was 23.3%, whereas of CLE with documented intestinal metaplasia was 14.1%. By time trend analysis, there was no significant changes in the prevalence of CLE over the study period. On univariate analysis, male gender, Caucasian race, heartburn duration > 5 years, presence and size of hiatal hernia were significantly associated with the presence of CLE. On multivariate analysis, heartburn duration > 5 years (OR, 1.50; 95% CI, 1.07-2.09), Caucasian race (OR, 2.40; 95% CI, 1.42-4.03), and hiatal hernia (OR, 2.07; 95% CI, 1.50-2.87) were found to be independent predictors for CLE. Therefore, they concluded that if BE is defined by the presence of CLE alone on upper endoscopy, up to 25% of GERD patients would be diagnosed with this lesion, and enrolling all these patients in surveillance programs would have significant ramifications on health-care resources.

Distal esophageal carcinomas in Chinese patients vary widely in histopathology, but adenocarcinomas remain rare

In Western countries, distal esophageal adenocarcinoma has outnumbered squamous cell carcinoma because of a dramatic increase in the prevalence of columnar-lined esophagus. Because the relative prevalence of these diseases remains unknown in China, we investigated the histopathology of distal esophageal neoplasm in resection specimens from a high-volume medical center in China. A computerized search of esophageal cancer was conducted in the pathology database between 2004 and 2010. Cancers with epicenter located within 5 cm above the gastroesophageal junction were retained for analysis. Pathology reports were reviewed along with medical, radiologic, and endoscopic records. All histology slides of selected cases were reevaluated (median, 13 per case). Conventional and basaloid squamous cell, adenosquamous, mucoepidermoid, and neuroendocrine carcinomas and esophageal adenocarcinoma were categorized according to the World Health Organization classification of esophageal cancers. The presence of columnar-lined esophagus and other pathologic changes were assessed in cases with residual esophageal mucosa. Among 1101 resections, 204 (19%) qualified for the study. Conventional and basaloid squamous cell, adenosquamous, mucoepidermoid, and neuroendocrine carcinomas and esophageal adenocarcinoma represented 76%, 11%, 3%, 2%, 6%, and 1% of the cases, respectively. Synchronous carcinomas were found in 12% and consisted of primarily squamous cell carcinoma (50%) and proximal gastric adenocarcinoma (38%). Columnar-lined esophagus was detected in 18% of the cases, among which intestinal metaplasia was present in 30% and low-grade dysplasia in 7%. In conclusion, distal esophageal carcinomas in Chinese patients showed a wide histopathologic spectrum with predominant squamous cell carcinoma and rare esophageal adenocarcinoma. Although common, columnar-lined esophagus appears pathogenetically insignificant for most distal esophageal carcinomas.

Is Cellular Senescence Commonly Found in Barrett's Esophagus?

Background: GEJ biopsies that contain inflamed squamous and columnar epithelium may represent distal esophageal columnar metaplasia or proximal gastritis (“carditis”). Pathologically, differentiation of these two disorders is difficult regardless of the presence or absence of goblet cells (GC). The aim of this study was to evaluate a wide variety of histologic features in GEJ biopsies, from a large prospective cohort of GERD patients, in order to determine their utility in predicting the presence of columnar-lined esophagus (CLE). Design: 2208 mucosal biopsies of the GEJ, from 552 GERD patients (M/F ratio: 305/247, mean age: 51 years), all of whom were endoscoped and interviewed prospectively as part of a large community clinic-based study of GERD patients in Washington state, were evaluated blindly for a wide variety of histologic features, such as mucosal and submucosal glands/ducts, multilayered epithelium (ME), type of glands (mucous, oxyntic, mixed), squamous islands, and buried columnar epithelium and correlated with the endoscopic evidence of, and length, of CLE, and with the presence of GC. The findings were also correlated with patient's clinical risk factors for BE, such as gender, race, waist:hip ratio, smoking history, and body mass index (BMI). Results: Overall, 56% of patients revealed CLE. The prevalence rates of relevant histologic features in GEJ biopsies were as follows: submucosal glands (0.6%), ducts (4%), ME (17%), GC (26%), mucous glands only (20%), oxyntic glands only (25%), mixed mucous/oxyntic glands (52%), squamous islands (15%), buried columnar epithelium (19%). The presence of ME (p=0.03), GC (p=0.001), pure mucous glands (p= 25, at least weekly heartburn, and increased waist:hip ratio (male≥0.9, female≥0.8) were all associated with CLE. Conclusion: Certain histologic features, such as submucosal glands and/or ducts, ME, pure mucous glands, squamous islands, and buried columnar epithelium, when detected in GEJ biopsies of GERD patients, are indicative of the presence of CLE at endoscopy. Any of these findings, even in the absence of GC, should warrant clinical suspicion for CLE in endoscopically ambiguous cases.

Red Meat Intake is Associated With Increased Risk of Barrett's Esophagus

Background: GEJ biopsies that contain inflamed squamous and columnar epithelium may represent distal esophageal columnar metaplasia or proximal gastritis (“carditis”). Pathologically, differentiation of these two disorders is difficult regardless of the presence or absence of goblet cells (GC). The aim of this study was to evaluate a wide variety of histologic features in GEJ biopsies, from a large prospective cohort of GERD patients, in order to determine their utility in predicting the presence of columnar-lined esophagus (CLE). Design: 2208 mucosal biopsies of the GEJ, from 552 GERD patients (M/F ratio: 305/247, mean age: 51 years), all of whom were endoscoped and interviewed prospectively as part of a large community clinic-based study of GERD patients in Washington state, were evaluated blindly for a wide variety of histologic features, such as mucosal and submucosal glands/ducts, multilayered epithelium (ME), type of glands (mucous, oxyntic, mixed), squamous islands, and buried columnar epithelium and correlated with the endoscopic evidence of, and length, of CLE, and with the presence of GC. The findings were also correlated with patient's clinical risk factors for BE, such as gender, race, waist:hip ratio, smoking history, and body mass index (BMI). Results: Overall, 56% of patients revealed CLE. The prevalence rates of relevant histologic features in GEJ biopsies were as follows: submucosal glands (0.6%), ducts (4%), ME (17%), GC (26%), mucous glands only (20%), oxyntic glands only (25%), mixed mucous/oxyntic glands (52%), squamous islands (15%), buried columnar epithelium (19%). The presence of ME (p=0.03), GC (p=0.001), pure mucous glands (p= 25, at least weekly heartburn, and increased waist:hip ratio (male≥0.9, female≥0.8) were all associated with CLE. Conclusion: Certain histologic features, such as submucosal glands and/or ducts, ME, pure mucous glands, squamous islands, and buried columnar epithelium, when detected in GEJ biopsies of GERD patients, are indicative of the presence of CLE at endoscopy. Any of these findings, even in the absence of GC, should warrant clinical suspicion for CLE in endoscopically ambiguous cases.

Update: histopathology-based definition of gastroesophageal reflux disease and Barrett's esophagus

BACKGROUND: Gastroesophageal reflux disease (GERD) is associated with columnar lined esophagus (CLE) and Barrett's esophagus (BE), which may progress towards esophageal adenocarcinoma. Currently a mixture of symptoms, endoscopic and histopathologic criteria and results obtained from esophageal function tests define GERD. We searched for a histopathology-based definition of GERD. METHODS: Review on GERD-histopathology. RESULTS: Multilevel biopsies and the novel Paull-Chandrasoma histopathology-classification of CLE define those with reflux and risk for development of esophageal adenocarcinoma (those with Barrett's esophagus and dysplasia) and list three abnormal nondysplastic epithelia between squamous and gastric oxyntic mucosa: cardiac mucosa (CM), oxyntocardiac mucosa (OCM), and CM with intestinal metaplasia (=Barrett's esophagus, with 0.5% annual cancer risk). Frequency of intestinal metaplasia (IM) is 15–24% at an endoscopically normal junction and increases towards 100% if CLE is ≥5 cm. IM develops at the squamocolumnar junction. Dilated end stage esophagus (DESE) is a novel concept and defines the early stage of reflux disease. The pathophysiology of DESE involves gastric distention-induced shortenings of the lower esophageal sphincter (LES) with reflux favoring damage and columnar metaplasia of the most distal esophagus. Over time permanent LES shortening and proximal dislocation of the squamocolumnar junction result in gastric-type appearance of DESE, which is mistaken for proximal stomach. The majority of adenocarcinomas of the "esophagogastric" junction arise within DESE. CONCLUSIONS: CLE is abnormal, results from reflux and is a disease if associated with life quality-impairing symptoms and/or intestinal metaplasia and dysplasia (cancer risk). Presence of CLE, IM, and dysplasia cannot be excluded from endoscopy, but requires histopathology of biopsies from the squamocolumnar junction.

The Quest for Intestinal Metaplasia–Is It Worth the Effort?

The columnar-lined esophagus (CLE) has remained an enigma for several decades. Starting with the basics, the definition and diagnosis of Barrett's esophagus (BE) continues to be a point of major debate globally leading to definitions that have been restrictive (requiring histologically confirmed intestinal metaplasia) or all-encompassing (simply the presence of CLE at endoscopy). The interest in intestinal metaplasia stems from studies that have consistently demonstrated intestinal metaplasia and dysplasia both adjacent to and remote from esophageal adenocarcinoma. The proponents of not requiring histology suggest that if a sufficient number of biopsies is obtained over an adequate period of time, intestinal metaplasia can usually be demonstrated in such cases and that the true neoplastic potential of the cardiac and fundic-type mucosa detected in the CLE has not been delineated. The optimal number of biopsies required to detect intestinal metaplasia is largely unknown, and in this issue of The American Journal of Gastroenterology, Harrison et al. add to the limited data on this subject. There is ample evidence that once a diagnosis of BE is made, it has significant implications on the financial, psychosocial, and insurance status of the patients. We feel that an optimal, practical definition of BE requires clear, accepted, reproducible, and clinically relevant criteria with evidence of an increased risk of cancer--the most crucial consequence of the lesion--and discuss the pros and cons of the need for documenting intestinal metaplasia in the CLE.

Barrett’s Esophagus – Who, How, How Often and What to Do with Dysplasia?

One of the issues I struggle with in gastroenterology is when, if and whom to screen for Barrett’s esophagus (BE). Although it is becoming common practice to screen patients with chronic reflux for BE, questions abound pertaining to whether screening is effective, as well as cost-effective, whom to screen and what to do when BE is found, not to mention the issues that arise when dysplasia is found. In light of the enormous clinical and economical implications of diagnosing patients with BE (1), some have questioned whether BE is a reasonable target for screening or whether resources would be better allocated to colon cancer prevention. Most patients agree to endoscopic screening when explained that the initial endoscopy is performed to search for an abnormal lining of the esophagus which, if present, has the potential to lead to esophageal cancer. What most of us do not explain, in any great detail at least, is what happens when and if dysplasia is found. Until recently, the finding of dysplasia led to anxiety on the part of the patient and physician. The potential therapeutic avenues included more intense surveillance or referral for esophagectomy, with its inherent risks and complications. It is possible that if these risks and complications were explained to patients in the beginning, a higher proportion would opt out of a surveillance program. On the other hand, there is evidence that suggests that the majority of patients overestimate the risk of developing adenocarcinoma of the esophagus, and this is worsened in patients who research their condition on the Internet (2), thus making our role as physicians and patient educators even more important. With the advent of more advanced and efficacious endoscopic therapy for dysplasia in BE, one hopes that the transition from diagnosis of BE to therapy of dysplasia will be smoother. DEFINITION AND EPIDEMIOLOGY The definition of BE has gone through several renditions to arrive at its current form: the presence of columnar-lined esophagus with specialized intestinal epithelium confirmed on biopsy. In the literature, the length of BE has been classified into long segment BE (3 cm or greater) and short segment BE (less than 3 cm). Although, when first described, short segment BE was thought to be associated with a much lower risk of esophageal adenocarcinoma, current evidence suggests that this risk is still significant and one cannot treat these patients differently than those with long segment BE (3,4). The risk estimation of esophageal adenocarcinoma in patients with BE varies widely, ranging from one per 99 patient years to one per 300 patient years (3-8).