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Unrecognized Barrett's Esophagus in Patients with Erosive Esophagitis Unveiled by Methylene Blue Chromoendoscopy
*W1583 Unrecognized Barrett's Esophagus in Patients with Erosive Esophagitis Unveiled by Methylene Blue Chromoendoscopy Stephen N. Wong, Jose D. Sollano Jr., Melchor M. Chan, Rolando Lopez, Johnny T. Go, Victoriano Y. Lim, Carmelita D. Dalupang, Ramon E. Carpio BACKGROUND: Recent guidelines recommend surveillance for patients with Barrett’s esophagus (BE), especially if dysplasia is present. However, in the background of erosive esophagitis (EE), endoscopic recognition of BE may be difficult. Up to 50% of patients with EE have an underlying BE discovered after the EE has healed. Methylene blue (MB) is avidly taken up by goblet cells found in columnar intestinal metaplasia (CIM), a hallmark of BE, and will stain these areas blue while leaving areas without CIM unstained. Thus, utilizing MB as a staining agent in chromoendoscopy may offer an opportunity to increase the endoscopic yield for BE in patients with EE. METHODS: All patients with EE but with no endoscopic evidence of BE were recruited into the study. Once EE was identified, 15cc of 0.5% methylene blue solution (MB) was sprayed around the distal esophagus and allowed to stay for 1-2 minutes before flushing with 100-200cc tap water. Three biopsies were then taken from both the stained and the unstained esophageal mucosa. If the distal esophageal mucosa did not stain, random biopsies from the unstained mucosa were taken. BE was confirmed if CIM was demonstrated on histopathology. Sensitivity, specificity, positive (PPV) and negative predictive values (NPV) were computed. RESULTS: A total of 51 patients (male: female; 1.4:1) were recruited into the study. Smoking and alcohol intake were more common in males (p=0.005 and p=0.023, respectively). Over half (52.1%) of the patients had symptoms >6 months prior to endoscopy. There was no difference in demographic and clinical data among patients with and without BE (p>0.05). Distribution of esophagitis severity according to the Los Angeles classification was as follows: A (n=36, 75%); B (n=11, 22.9%); C (n=1, 2.1%). MB uptake was noted in 91.7% (n=44), 38 (86.4%) of whom were confirmed to have CIM on histopathology. In 3 patients who exhibited positive dye uptake, biopsies on both the stained and unstained mucosa revealed CIM. The sensitivity, specificity, PPV and NPV of MB chromoendoscopy for the diagnosis of BE were 92.7%, 88.2%, 86,4% and 93.8%, respectively. There was no correlation between esophagitis severity and the presence of BE (p=0.294). CONCLUSIONS: Endoscopically unrecognized BE is highly prevalent in patients with EE. MB chromoendoscopy demonstrates high sensitivity and specificity in the diagnosis of BE and is a valuable tool in unmasking this disease in patients with EE.
*W1584 Barrett's Esophagus Screening: Is Age Really a Factor? Tammy Glenn, Carolyn Reed, Robert H. Hawes Background: Known risk factors for Barrett’s esophagus include male gender, Caucasian race and history of heartburn. It has been suggested that increased age may also be a risk factor and thus many advocate a screening EGD for those with longstanding GERD with age greater than 50. Methods: Adult heartburn patients without dyspepsia or dysphagia underwent a small caliber esophagoscopy without sedation performed by a Nurse Practitioner trained in esophagoscopy. Patients with significant finding (Columnar lined esophagus >5 mm, esophagitis sufficient to obstruct the view of the GEJ, nodules and rings) were referred to a gastroenterologist for standard EGD. Results: Of the 410 patients screened, 18 had confirmed Barrett’s (intestinal metaplasia per path). Average years of symptoms = 16. 13-Caucasian males, 3- Caucasian females, 1- African American male, 1- African American female. Patient’s ages are as follows. Conclusion: Male gender and Caucasian race are certainly strong risk factors for Barrett’s esophagus, but perhaps increased age should be secondary. 1/3 of patients in this study were diagnosed prior to age 50, and 72% were diagnosed prior to age 55. When making decisions on screening for Barrett’s in the GERD patient, perhaps age should not be a deciding factor.
P262
GASTROINTESTINAL ENDOSCOPY
*W1585 DNA Ploidy Analysis with Image Cytometry on Barrett's Esophagus-related Dysplasia and Esophageal Adenocarcinoma Chenggong Yu, Qin Huang, Michael Klein, Raj K. Goyal Background and Aims: Barrett’s esophagus is of great clinical importance to correctly grade precursor lesions histopathologically and to identify the patients with a high risk of developing invasive malignancy for early management. Regrettably, the pathological identification of early malignancy is subjective and has high inter-observer variations, and none of the molecular markers have been proven to be sensitive and specific for this purpose also. In our previous study, we found that DNA ploidy analysis was much better than histopathology for identifying premalignant lesions in the patients with Barrett’s esophagus. In the current study, we wish to expand the on-going image cytometry study using the Automated Cellular Image System (ACIS) to measure DNA content in tissue. Methods: The cases with Barrett’s esophagus or distal esophageal adenocarcinoma were retrieved from the computer files. The lesions were identified, classified, and marked on slides by two experienced pathologists. The corresponding tissue blocks were retrieved and cut at 7 mM. The sections were then Feulgen stained. DNA content was measured and analyzed with ACIS. The control nuclei of cells with DNA index (DI) between 0.90-1.10 consisted of those of benign stromal cells including endothelial cells, fibroblasts, macrophages, and large lymphocytes. DNA content histograms were classified into near diploidy/aneuploidy (DI: 1.111.30), low aneuploidy (DI: 1.31-1.90), tetraploidy (DI: 1.91-2.10), and high aneuploidy (DI: >2.11). Results: Of the 50 cases studied, 10 were gastric cardiac mucosa without dysplasia (CM), 10 with Barrett’s esophagus without dysplasia (BE), 5 with indefinite dysplasia (ID), 9 with low-grade dysplasia (LD), 8 with high-grade dysplasia (HD), and 8 with esophageal adenocarcinoma (EA). DNA ploidy status was found in various patterns and the cases with non-diploidy including aneuploidy were identified in 0/10 CM, 8/10 BE, 4/5 ID, 6/9 LD, 8/8 HD, and 8/8 EA cases. The mean DI for each disease was 1.05 for CM, 1.20 for BE, 1.38 for ID, 1.37 for LD, 1.83 for HD, and 1.97 for EA. The results indicate that nondiploidy is common in Barrett’s esophagus-related lesions and DNA image cytometry is able to identify malignant cells in the early premalignant diseases. Conclusion: DNA content image cytometry appears to be a sensitive method for identifying premalignant lesions in Barrett’s esophagus-related diseases.
*W1586 Temporal Change in Barrett's Esophagus Segment Length (BESL) During Prospective Surveillance Leilani M. Sharpe, Xiaohong Li, David Cowan, Brian J. Reid, Douglas S. Levine, Kamran Ayub, Patricia L. Blount Background: Few studies have explored changes in BESL during prospective endoscopic surveillance. The aim of this study was to investigate BESL changes during prospective surveillance and factors contributing to BESL change. Methods: Endoscopic landmarks were followed prospectively in 467 patients for an average of 5 years and changes in BESL were monitored at well-defined endoscopic intervals and recorded in a database. Individuals with BESL change outside of the expected statistical variation during follow-up were further analyzed for contributing patient and environmental factors. Results: 79 of the 467 patients (17%) had significant change in BESL during follow-up whereas the BESL remained stable in 338 patients (83%). There was no statistical difference in BESL changes between males and females (two tail t-test p >0.2). There was also no significant difference between rates of BESL change for those patients who were followed for <2 years compared to those followed for >6 years. No significant changes occurred in the BESL rate of change as a function of baseline segment length. Total regression of the BE segment was significantly associated with a smaller hiatal hernia (p<0.0001). Additionally, the mean baseline BESL of those patients who had total regression of their BE segment was significantly shorter as compared to patients without complete regression (2.4cm vs. 5.8cm; p<0.001). However, there was no significant difference in hiatal hernia size among patients whose BESL increased, remained stable, or decreased. There was a significant association between the duration of PPI use and the rate of decrease of BESL (p trend = 0.027). Conclusions: (1) Most BESLs remain stable during prospective follow-up. (2) Smaller hiatal hernia and shorter baseline BESL increase a patient’s likelihood of complete regression of BE. (3) Extended treatment with PPIs appears to contribute to decreased BESL. (4) Patient gender and the length of follow-up do not seem to affect the rate of change of a Barrett’s segment length.
VOLUME 59, NO. 5, 2004
*W1584 Barrett's Esophagus Screening: Is Age Really a Factor? Tammy Glenn, Carolyn Reed, Robert H. Hawes Background: Known risk factors for Barrett’s esophagus include male gender, Caucasian race and history of heartburn. It has been suggested that increased age may also be a risk factor and thus many advocate a screening EGD for those with longstanding GERD with age greater than 50. Methods: Adult heartburn patients without dyspepsia or dysphagia underwent a small caliber esophagoscopy without sedation performed by a Nurse Practitioner trained in esophagoscopy. Patients with significant finding (Columnar lined esophagus >5 mm, esophagitis sufficient to obstruct the view of the GEJ, nodules and rings) were referred to a gastroenterologist for standard EGD. Results: Of the 410 patients screened, 18 had confirmed Barrett’s (intestinal metaplasia per path). Average years of symptoms = 16. 13-Caucasian males, 3- Caucasian females, 1- African American male, 1- African American female. Patient’s ages are as follows. Conclusion: Male gender and Caucasian race are certainly strong risk factors for Barrett’s esophagus, but perhaps increased age should be secondary. 1/3 of patients in this study were diagnosed prior to age 50, and 72% were diagnosed prior to age 55. When making decisions on screening for Barrett’s in the GERD patient, perhaps age should not be a deciding factor.
P262
GASTROINTESTINAL ENDOSCOPY
*W1585 DNA Ploidy Analysis with Image Cytometry on Barrett's Esophagus-related Dysplasia and Esophageal Adenocarcinoma Chenggong Yu, Qin Huang, Michael Klein, Raj K. Goyal Background and Aims: Barrett’s esophagus is of great clinical importance to correctly grade precursor lesions histopathologically and to identify the patients with a high risk of developing invasive malignancy for early management. Regrettably, the pathological identification of early malignancy is subjective and has high inter-observer variations, and none of the molecular markers have been proven to be sensitive and specific for this purpose also. In our previous study, we found that DNA ploidy analysis was much better than histopathology for identifying premalignant lesions in the patients with Barrett’s esophagus. In the current study, we wish to expand the on-going image cytometry study using the Automated Cellular Image System (ACIS) to measure DNA content in tissue. Methods: The cases with Barrett’s esophagus or distal esophageal adenocarcinoma were retrieved from the computer files. The lesions were identified, classified, and marked on slides by two experienced pathologists. The corresponding tissue blocks were retrieved and cut at 7 mM. The sections were then Feulgen stained. DNA content was measured and analyzed with ACIS. The control nuclei of cells with DNA index (DI) between 0.90-1.10 consisted of those of benign stromal cells including endothelial cells, fibroblasts, macrophages, and large lymphocytes. DNA content histograms were classified into near diploidy/aneuploidy (DI: 1.111.30), low aneuploidy (DI: 1.31-1.90), tetraploidy (DI: 1.91-2.10), and high aneuploidy (DI: >2.11). Results: Of the 50 cases studied, 10 were gastric cardiac mucosa without dysplasia (CM), 10 with Barrett’s esophagus without dysplasia (BE), 5 with indefinite dysplasia (ID), 9 with low-grade dysplasia (LD), 8 with high-grade dysplasia (HD), and 8 with esophageal adenocarcinoma (EA). DNA ploidy status was found in various patterns and the cases with non-diploidy including aneuploidy were identified in 0/10 CM, 8/10 BE, 4/5 ID, 6/9 LD, 8/8 HD, and 8/8 EA cases. The mean DI for each disease was 1.05 for CM, 1.20 for BE, 1.38 for ID, 1.37 for LD, 1.83 for HD, and 1.97 for EA. The results indicate that nondiploidy is common in Barrett’s esophagus-related lesions and DNA image cytometry is able to identify malignant cells in the early premalignant diseases. Conclusion: DNA content image cytometry appears to be a sensitive method for identifying premalignant lesions in Barrett’s esophagus-related diseases.
*W1586 Temporal Change in Barrett's Esophagus Segment Length (BESL) During Prospective Surveillance Leilani M. Sharpe, Xiaohong Li, David Cowan, Brian J. Reid, Douglas S. Levine, Kamran Ayub, Patricia L. Blount Background: Few studies have explored changes in BESL during prospective endoscopic surveillance. The aim of this study was to investigate BESL changes during prospective surveillance and factors contributing to BESL change. Methods: Endoscopic landmarks were followed prospectively in 467 patients for an average of 5 years and changes in BESL were monitored at well-defined endoscopic intervals and recorded in a database. Individuals with BESL change outside of the expected statistical variation during follow-up were further analyzed for contributing patient and environmental factors. Results: 79 of the 467 patients (17%) had significant change in BESL during follow-up whereas the BESL remained stable in 338 patients (83%). There was no statistical difference in BESL changes between males and females (two tail t-test p >0.2). There was also no significant difference between rates of BESL change for those patients who were followed for <2 years compared to those followed for >6 years. No significant changes occurred in the BESL rate of change as a function of baseline segment length. Total regression of the BE segment was significantly associated with a smaller hiatal hernia (p<0.0001). Additionally, the mean baseline BESL of those patients who had total regression of their BE segment was significantly shorter as compared to patients without complete regression (2.4cm vs. 5.8cm; p<0.001). However, there was no significant difference in hiatal hernia size among patients whose BESL increased, remained stable, or decreased. There was a significant association between the duration of PPI use and the rate of decrease of BESL (p trend = 0.027). Conclusions: (1) Most BESLs remain stable during prospective follow-up. (2) Smaller hiatal hernia and shorter baseline BESL increase a patient’s likelihood of complete regression of BE. (3) Extended treatment with PPIs appears to contribute to decreased BESL. (4) Patient gender and the length of follow-up do not seem to affect the rate of change of a Barrett’s segment length.
VOLUME 59, NO. 5, 2004