⁎3527 MAGNIFYING ENDOSCOPY CAN MAKE THE DIAGNOSIS OF SPECIALIZED INTESTINAL METAPLASIA AT THE ESOPHAGOGASTRIC JUNCTION.

*3525 DO GASTROESOPHAGEAL REFLUX INDUCED CHANGES IN THE SQUAMOUS MUCOSA HAVE A POSITIVE ASSOCIATION WITH THE PRESENCE OF THE INTESTINAL METAPLASIA OF BARRETT’S ESOPHAGUS? Christian Jost, David N. Lewin, Hugh E. Mulcahy, Robert H. Hawes, Med Univ of South Carolina, Charleston, SC. There appears to be a close pathophysiological relationship between Barrett’s esophagus and gastroesophageal reflux. In patients with GERD, pathologists often describe tissue changes of the squamous mucosa that are acknowledged as being induced by gastroesophageal reflux. PURPOSE We tested the hypothesis that histopathological reflux induced changes in squamous mucosa have a positive correlation with the presence of goblet cells or intestinal metaplasia without goblet cells in patients with endoscopic features of Barrett’s esophagus. METHODS Systematic histopathological review by a single experienced gastrointestinal histopathologist (D.N.L.) of biopsy sample collections from 160 patients (143 Caucasian, median age 52 y [range 26-89], 82 males) with the endoscopical feature of gastric mucosa proximal to the gastric folds. The histopathologist specifically assessed the presence of i) goblet cells in columnar lined mucosa, ii) inflammatory infiltration in the glandular mucosa, and iii) reflux induced changes in squamous mucosa. These are Intraepithelial Eosinophils in squamous epithelium, Basal Cell Hyperplasia if basal cell layer thicker than 15% of the epithelium s thickness, Papillae & Rete Elongation if Papilla/Epithelium ratio over 2/3. For the statistical analysis we categorized the sample collections in three groups: (A) intestinal metaplasia with goblet cells, (B) intestinal metaplasia without goblet cells, and (C) no intestinal metaplasia. RESULTS The three groups (A) n = 67, (B) n = 36, and (C) n = 57 had equally frequent inflammatory infiltration - interpreted as acute for (A) in 21%, (B) in 25%, (C) in 23% (p = 0.89); and - interpreted as chronic for (A) 22%, (B) 28%, and (C) 26% (p = 0.80). Intraepithelial Eosinophils were found in group (A) 18%, in (B) 6%, and in (C) 19% (p = 0.16). Basal Cell Hyperplasia was found in group (A) 21%, in (B) 3%, and in (C) 19% (p = 0.04). Papillae & Rete Elongation was found in group (A) 23%, in (B) 33%, and in (C) 40% (p = 0.16). CONCLUSION Gastroesophageal reflux induced changes in squamous mucosa occur at similar frequencies in patients with intestinal metaplasia containing goblet cells, intestinal metaplasia without goblet cells, and in those without intestinal metaplasia. Thus, although Barrett’s esophagus is assumed to occur as a result of gastroesophageal reflux, histopathological features of reflux in squamous mucosa correspond poorly with the presence of intestinal metaplasia. *3526 BARRETT’S ESOPHAGUS. SURVEILLANCE FOR SHORT AND LONG SEGMENT DISEASE. S. David Feldshon, Jennie L. Rodlund, Minnesota GI, Minneapolis, MN. Background: Long segment Barrett’s Esophagus (LSBE) is a precursor of adenocarcinoma of the esophagus and surveillance is part of accepted management. Short segment Barrett’s Esophagus (SSBE) is diagnosed with uncertain frequency and carries an unclear cancer risk. Methods: 152 patients with Barrett’s esophagus (BE) were identified via billing and medical records of a large GI practice for the period 1/98-11/99. The diagnosis of BE required a verbal description of abnormal mucosa above the EG junction plus a pathologic diagnosis of specialized columnar epithelium or goblet cells. 50 patients were found to have SSBE with less than 3 cm of abnormal mucosa. There were 7 patients with low grade dysplasia (LGD) or indefinite dysplasia (ID) on biopsy. No patient with SSBE had high grade dysplasia (HGD) or cancer. There were 16 separate endoscopies(EGD’s) with some dysplasia(10% of 159 SSBE EGD’s) or 13% risk of dysplasia/year of surveillance. 102 patients had LSBE. 34 patients had 85 EGD’s with some dysplasia noted (20% of 423 EGD’s) or 18%risk of dysplasia/year of surveillance. 8 EGD’s revealed HGD. Three esophageal cancers were identified (2 on initial EGD) and 2 other patients had surgery for HGD. Total years of surveillance were 478 for LSBE and 123 for SSBE. Average surveillance interval was 15.7 months for both groups. We conclude that SSBE is commonly diagnosed and constitutes 1/3 of our BE patients. The cancer risk in both SSBE and LSBE appears to be well under 1 per 100 years of surveillance. The dysplasia risk per year of surveillance was higher than expected for SSBE and suggests that SSBE is not a benign condition. We intend to follow these patients longitudinally, but increase the surveillance interval, especially in those without dysplasia. Dysplasia

SSBE (n=50)

LSBE (n=102)

4 4 0 0 16/159

25 14 8 3 85/423

LGD Indefinite Dysplasia HGD Adenocarcinoma total EGD’s with dysplasia

VOLUME 51, NO. 4, PART 2, 2000

*3527 MAGNIFYING ENDOSCOPY CAN MAKE THE DIAGNOSIS OF SPECIALIZED INTESTINAL METAPLASIA AT THE ESOPHAGOGASTRIC JUNCTION. Eunice B. Tonelotto, Ronaldo S. Torresini, Nelson V. Coelho, Anis Kurban, Fugast, Porto Alegre, Brazil. Current endoscopic techniques are inadequate to identify subtle changes in the gastrointestinal mucosa. Development of high resolution and magnifying equipments have enabled the endoscopic recognition of minor changes occurring in the surface epithelium. The AIM of this study is to evaluate the magnifying endoscopic features of the esophagogastric junction (EG-juntion) and the correlation with histologic findings. METHODS A total of 44 patients with upper digestive complaints consecutively examined and after written informed consent were included in the study. After spraying of indigo-carmine 2% at the EG-junction all cases were examined in detail with magnifying endoscope (FUJINON 410CR) which gives a 40x image magnification. The magnifying endoscopic appearance of the EGJunction was classified into 2 patterns: Type I = small,uniformly arranged, rounded glands and Type II= dilated, convoluted, tortuos glands. Four biopsy specimens were taken from the EG-junction in each patient. RESULTS Type I EG-junction was observed in 24 patients and Type II in 20 patients. In all 24 cases(100%)with Type I EG-junction histologic findings confirmed normal or inflammatory-hyperplastic cardiac mucosa. However, among the 20 cases with type II EG-junction, 17(85%) showed specialized intestinal metaplasia on histologic examination. In the other 3 cases (15%) of Type II EG-junction marked foveolar hyperplasia of cardiac glands was observed. Type II EG-junction on magnifying endoscopic examination was significantly (p<0.05) correlated with the histologic diagnosis of specialized intestinal metaplasia. CONCLUSION Magnifying (40x) endoscopic examination with indigo-carmine staining of EG-junction is useful to recognize specialized intestinal metaplasia. Clinical application of this new endoscopic modality might be useful for the detailed study of EG-junction related disorders. *3528 USEFULNESS OF DOUBLE DYE STAINING (METHYLENE BLUE AND CRYSTAL VIOLET) FOR THE MAGNIFYING OBSERVATION OF INTESTINAL METAPLASIA IN BARRETT’S ESOPHAGUS. Nobuo Sueoka, Hitoshi Nisigaki, Masaoki Yonezawa, Taku Tsukui, Choitsu Sakamoto, Masafumi Tabuchi, Nippon Med Sch, Tokyo, Japan; Nakameguro Shoukaki Clin, Univ of Tokyo, Tokyo, Japan. Backgroud: Barrett’s esophagus (BE) is the metaplastic replacement of normal squamous epithelium by columnar epithelium. Canto et al. have reported (Gastrointest Endosc 1996) that the value of methylene blue(MB) staining of visible columnar epithelium in the esophagus to help obtain targeted biopsies with the purpose of improving diagnostic yield of intestinal metaplasia (IM). MB staining is sometimes unclear to observe a fine surface structure of Barrett’s epithelium. Aim:To determine MB staining is useful to detect IM in Barrett’s patients or not. Next,to evaluate the accuracy of representing a surface structure of IM in magnifying endoscopic observation with double dye staining. Methods: Twenty-eight consecutive patients undergoing high-resolution magnifying endoscopy (Fujinon EG410CR) with dye staining for Barrett’s patients and non BE patients (atrophic gastritis). Eight patients had long segment BE (length of columnar lined epithelium>2cm), 10 patients had short segment Barrett’s esophagus (SSBE) and 10 patients had no Barrett’s (normal EG-junction). Staining proceeding: The first procedure was washing out the mucous in the esophagus with a bolus water and MB 0.5 % (10ml) was sprayed, after 4 minutes the surface was cleaned with water. MB stained area of columnar epithelium in the esophagus and near the EG-junction (non BE) were classified into 4 grades; grade 0: 0%, grade 1: 10-30%, grade 2: 30-60%, grade3:60-100%. Then, 0.05% crystal violet (CV; 5ml) was sprayed and magnified surface structure was observed. Target biopsies were performed from these areas (grade0-3). Results: 1) BE and SSBE subject; non-MB staining sites (grade 0) on target biopsies revealed IM in 0/28 (0 %). Patchy (grade 1), Focal (grade2), and Diffuse (grade 3) staining sites revealed IM, 11/33 (33%), 32/48 (67%), and8/8 (100%). 2) non BE and no SSBE subject; Target biopsies revealed IM were as follows: grade 0; 0/10 (0%), grade 1 (4/5) 80%, grade 2; 7/8 (88%), grade 3; 2/2 (100 %). All biopsies sites were considered at the cardiac area nearby EG-junction. 3) CV solution directly dyes the surface of the Barrett’s epithelium, and enhanced the MB stained mucosa, so a very clear and fine mucosal patterns was observed. Conclusions: In this prospective study, MB staining with target biopsies improve the diagnostic yield for BE and SSBE, furthermore, double dye staining (MB and CV) is very useful to observe the mucosal structure of Barrett’s epithelium.

GASTROINTESTINAL ENDOSCOPY

AB117