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Should We Biopsy an Irregular Z-Line? The Yield of Biopsy to Diagnose Short-Segment Barrett's Esophagus
*W1591 Acetic Acid Magnification ChromoEndoscopy Detects All Focal High Grade Dysplasia in Barrett's Esophagus Michael Miros, David Cohn, Neal Walker Due to sampling error early High Grade Dysplasia (HGD) can be difficult to detect during surveillance of Barretts Esophagus (BE). AIM: To asess whether the use of Magnification chromoendoscopy (MCE) can detect early HGD. METHOD: All patients presenting for a routine surveillance endoscopy for BE over an 18 month period (June 2002-Nov 2003) had 1.5% Acetic Acid MCE performed using an Olympus 160 zoom endoscope. Routine four quadrant biopsies were performed every 2 cm of normal appearing BE mucosa with a type 3 or 4 pit pattern. Areas with an irregular pit pattern were separately biopsied.Histology was reviewed by 2 experienced gastro pathologists. RESULTS: MCE detected all 4 patients with focal HGD (3 short segment and 1 long segment) out of a total of 385 BE patients. The areas of HGD varied from 3 mm to 8 mm in diameter all of which exhibited an irregular pit pattern. All patients had the HGD successfully treated with endoscopic mucosal resection with no evidence of invasive malignancy. 5 patients with linear irregularities in pit pattern had inflammatory histology only. 1 patient with no irregularity was diagnosed as possible HGD but on repeat biopsies after intense reflux treatment was downgraded to low grade dysplasia. Low grade dysplasia was present in 76 patients (none with irregularity in pit pattern with MCE) CONCLUSION: Acetic Acid MCE appears useful in the early detection of focal HGD in BE. It is used routinely in our clinic.
included ‘‘inflammation’’ in 158 (43%) and histologic esophagitis in 43 (12%). Conclusions: The yield of biopsy at an ‘‘irregular z-line’’ is low. In addition, the risk of cancer in patients with this endoscopic finding and specialized intestinal metaplasia (even with dysplasia) is unknown. We would, therefore, suggest that this terminology be abandoned. We recommend endoscopists adopt a precise description of irregularity at the SCJ and that BE only be diagnosed when tissue is obtained from the tubular esophagus. Additional study is needed to better define the landmarks at the SCJ and to determine the risk of malignancy in patients with SIM in different parts of the upper gastrointestinal tract.
*W1592 Acetic Acid Chromoendoscopy Improved Detection of Islands of Barrett's Epithelium in GERD Patients H. K. Kim, S. H. Park, J. K. Kim, Kyu-Young Choi, In-Sik Chung, K. W. Chung, H. S. Sun Purpose: The diagnosis of Barrett’s esophagus by endoscopy could be difficult by visual inspection. The methylene blue stain already used for improving endoscopic surveillance in Barrett’s esophagus. But sensitivity of staining is significantly affected by esophagitis. Acetic acid produces reversible intracellular cytoplasmic protein denaturation and differentiates Barrett’s epithelium from squamous epithelium in gastroesophageal junction. The sensitivity of acetic acid chromoscopy for islands of Barrett’s epithelium is unexplored in GERD patients. The aim of study is to investigate the diagnostic yield of acetic acid staining for Barrett’s epithelium in GERD patients. Methods: We prospectively evaluate the accuracy and diagnostic yield of acetic acid directed biopsy in detecting island of Barrett’s epithelium in GERD patients. Chromoendoscopy of the distal esophagus with 1.5% acetic acid was performed on 78 patients and 10 healthy volunteers. We obtained 91 biopsy specimens from GERD patients and 10 biopsy specimens from healthy volunteers. Results: Acetic acid staining specimens were 85 of 101 specimens (84.2%). The overall accuracy of acetic acid staining for detecting Barrett epithelium was 80.2%. In visual inspection, the overall accuracy of Barrett’s islands was 48.4%. Acetic acid unstaining specimens for diagnosed as reflux esophagitis and healthy volunteers were 13 of 16(81.3%) specimens. The, sensitivity, specificity, positive and negative predictive value of acetic acid chromoscopy were 95.8%, 43.3%, 80.0%, and 81.3%, respectively. Conclusion: Acetic acid chromoscopy increased diagnostic accuracy for detection of island of Barrett’s epithelium in GERD patients.
*W1593 Should We Biopsy an Irregular Z-Line? The Yield of Biopsy to Diagnose Short-Segment Barrett's Esophagus Dawn D. Ferguson, Kenneth R. DeVault, Herbert C. Wolfsen Background: The diagnosis of Barrett’s esophagus (BE) requires the demonstration of specialized intestinal metaplasia (SIM) within the tubular esophagus. Unfortunately, the endoscopic demarcation between the distal esophagus and proximal stomach is often unclear. This results in the common endoscopic diagnosis of ‘‘irregular z-line.’’ The yield of biopsy of this area to determine the presence of specialized intestinal metaplasia is the subject of this report. Methods: The charts of all patients presenting for elective upper endoscopy at the Mayo Clinic Jacksonville between 7/1/03 and 10/31/03 were reviewed. The endoscopic and histologic findings were recorded from that review. Biopsies were evaluated by dedicated pathologists who made the diagnosis of specialized intestinal metaplasia based on the presence of typical goblet cell containing mucosa on routine staining. Results: 1521 upper endoscopies were performed during the study period. 366 (24%) of these had ‘‘irregular z-line’’ listed as an endoscopic finding with subsequent biopsies obtained of the columnar appearing mucosa below the squamocolumnar junction (SCJ). In addition to an irregular z-line, other endoscopic findings in these 366 patients included: hiatal hernia, 76 (21%); esophagitis, 35 (10%); Schatzki’s ring, 18 (5%), and; inlet patch 6 (2%). On histology, 94/366 (26%) biopsies were shown to have specialized intestinal metaplasia and of these two had low-grade dysplasia. Other histological findings
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*W1594 Duration of Heartburn Is the Only Symptom Characteristic That Distinguishes Between Patients with Long Segment (LSBE) and Those with Short Segment Barrett's Esophagus (SSBE) Jimmy Kim, Lisa Camargo, Richard E. Sampliner, Harinder S. Garewal, Ronnie Fass Purpose: Symptom characteristics of GERD, such as duration, severity or frequency have been suggested to be predictive of BE. However, thus far there are no studies that have assessed the value of these symptom characteristics in identifying patients with SSBE versus those with LSBE. Aim: To determine if any of the symptom characteristics of gastroesophageal reflux disease (GERD) can distinguish between patients with LSBE and those with SSBE. Methods: Patients seen in our Barrett’s clinic were prospectively approached and asked to participate in this study. All patients underwent an endoscopy, which carefully documented the length of their Barrett’s mucosa by an experienced endoscopist. LSBE was defined as $3 cm and SSBE as <3 cm. Characteristics of GERD symptoms were evaluated by the previously validated GERD symptoms Checklist. Analysis focused on 4 domains, duration of symptom (years), frequency of symptom (per week), severity of symptom (1-4 scale) and symptom intensity (calculated as frequency 3 severity). Results: 88 BE patients were recruited into the study. 47 had SSBE (mean age 67.6 6 1.4, range- 51-86, M/F-46/1) and 41 LSBE (mean age 68.0 6 2.0, range- 29-86, M/F-38/3). 44 (93.6%) of the SSBE patients and 38 (92.7%) of the LSBE patients reported heartburn. There was no significant difference in the frequency, severity and intensity of heartburn between the SSBE and the LSBE group (17.0 6 1.8 vs. 16.7 6 2.3 p=0.9, 2.7 6 0.1 vs. 2.6 6 0.1 p = 0.4 and 46.4 6 5.3 vs. 46.3 6 6.7 p=1.0, respectively). However, duration of heartburn symptom was significantly longer in the LSBE group as compared to the SSBE group (31.0 6 3.0 vs. 24.5 6 2.2, p<0.05). 38 (81%) of SSBE patients and 34 (83%) of LSBE patients reported regurgitation. There was no significant difference in the duration, frequency, severity and intensity of regurgitation symptom between patients with SSBE and those with LSBE (p=0.4, p=0.9, p=0.3 and p=0.6, respectively). No difference in the prevalence and symptom characteristics of nocturnal GERD symptoms, chest pain and dysphagia was found between the two BE groups. Conclusion: Duration of heartburn symptom is the sole symptom characteristic that distinguishes between patients with LSBE (higher risk for esophageal cancer) and those with SSBE (lower risk for esophageal cancer).
VOLUME 59, NO. 5, 2004
included ‘‘inflammation’’ in 158 (43%) and histologic esophagitis in 43 (12%). Conclusions: The yield of biopsy at an ‘‘irregular z-line’’ is low. In addition, the risk of cancer in patients with this endoscopic finding and specialized intestinal metaplasia (even with dysplasia) is unknown. We would, therefore, suggest that this terminology be abandoned. We recommend endoscopists adopt a precise description of irregularity at the SCJ and that BE only be diagnosed when tissue is obtained from the tubular esophagus. Additional study is needed to better define the landmarks at the SCJ and to determine the risk of malignancy in patients with SIM in different parts of the upper gastrointestinal tract.
*W1592 Acetic Acid Chromoendoscopy Improved Detection of Islands of Barrett's Epithelium in GERD Patients H. K. Kim, S. H. Park, J. K. Kim, Kyu-Young Choi, In-Sik Chung, K. W. Chung, H. S. Sun Purpose: The diagnosis of Barrett’s esophagus by endoscopy could be difficult by visual inspection. The methylene blue stain already used for improving endoscopic surveillance in Barrett’s esophagus. But sensitivity of staining is significantly affected by esophagitis. Acetic acid produces reversible intracellular cytoplasmic protein denaturation and differentiates Barrett’s epithelium from squamous epithelium in gastroesophageal junction. The sensitivity of acetic acid chromoscopy for islands of Barrett’s epithelium is unexplored in GERD patients. The aim of study is to investigate the diagnostic yield of acetic acid staining for Barrett’s epithelium in GERD patients. Methods: We prospectively evaluate the accuracy and diagnostic yield of acetic acid directed biopsy in detecting island of Barrett’s epithelium in GERD patients. Chromoendoscopy of the distal esophagus with 1.5% acetic acid was performed on 78 patients and 10 healthy volunteers. We obtained 91 biopsy specimens from GERD patients and 10 biopsy specimens from healthy volunteers. Results: Acetic acid staining specimens were 85 of 101 specimens (84.2%). The overall accuracy of acetic acid staining for detecting Barrett epithelium was 80.2%. In visual inspection, the overall accuracy of Barrett’s islands was 48.4%. Acetic acid unstaining specimens for diagnosed as reflux esophagitis and healthy volunteers were 13 of 16(81.3%) specimens. The, sensitivity, specificity, positive and negative predictive value of acetic acid chromoscopy were 95.8%, 43.3%, 80.0%, and 81.3%, respectively. Conclusion: Acetic acid chromoscopy increased diagnostic accuracy for detection of island of Barrett’s epithelium in GERD patients.
*W1593 Should We Biopsy an Irregular Z-Line? The Yield of Biopsy to Diagnose Short-Segment Barrett's Esophagus Dawn D. Ferguson, Kenneth R. DeVault, Herbert C. Wolfsen Background: The diagnosis of Barrett’s esophagus (BE) requires the demonstration of specialized intestinal metaplasia (SIM) within the tubular esophagus. Unfortunately, the endoscopic demarcation between the distal esophagus and proximal stomach is often unclear. This results in the common endoscopic diagnosis of ‘‘irregular z-line.’’ The yield of biopsy of this area to determine the presence of specialized intestinal metaplasia is the subject of this report. Methods: The charts of all patients presenting for elective upper endoscopy at the Mayo Clinic Jacksonville between 7/1/03 and 10/31/03 were reviewed. The endoscopic and histologic findings were recorded from that review. Biopsies were evaluated by dedicated pathologists who made the diagnosis of specialized intestinal metaplasia based on the presence of typical goblet cell containing mucosa on routine staining. Results: 1521 upper endoscopies were performed during the study period. 366 (24%) of these had ‘‘irregular z-line’’ listed as an endoscopic finding with subsequent biopsies obtained of the columnar appearing mucosa below the squamocolumnar junction (SCJ). In addition to an irregular z-line, other endoscopic findings in these 366 patients included: hiatal hernia, 76 (21%); esophagitis, 35 (10%); Schatzki’s ring, 18 (5%), and; inlet patch 6 (2%). On histology, 94/366 (26%) biopsies were shown to have specialized intestinal metaplasia and of these two had low-grade dysplasia. Other histological findings
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*W1594 Duration of Heartburn Is the Only Symptom Characteristic That Distinguishes Between Patients with Long Segment (LSBE) and Those with Short Segment Barrett's Esophagus (SSBE) Jimmy Kim, Lisa Camargo, Richard E. Sampliner, Harinder S. Garewal, Ronnie Fass Purpose: Symptom characteristics of GERD, such as duration, severity or frequency have been suggested to be predictive of BE. However, thus far there are no studies that have assessed the value of these symptom characteristics in identifying patients with SSBE versus those with LSBE. Aim: To determine if any of the symptom characteristics of gastroesophageal reflux disease (GERD) can distinguish between patients with LSBE and those with SSBE. Methods: Patients seen in our Barrett’s clinic were prospectively approached and asked to participate in this study. All patients underwent an endoscopy, which carefully documented the length of their Barrett’s mucosa by an experienced endoscopist. LSBE was defined as $3 cm and SSBE as <3 cm. Characteristics of GERD symptoms were evaluated by the previously validated GERD symptoms Checklist. Analysis focused on 4 domains, duration of symptom (years), frequency of symptom (per week), severity of symptom (1-4 scale) and symptom intensity (calculated as frequency 3 severity). Results: 88 BE patients were recruited into the study. 47 had SSBE (mean age 67.6 6 1.4, range- 51-86, M/F-46/1) and 41 LSBE (mean age 68.0 6 2.0, range- 29-86, M/F-38/3). 44 (93.6%) of the SSBE patients and 38 (92.7%) of the LSBE patients reported heartburn. There was no significant difference in the frequency, severity and intensity of heartburn between the SSBE and the LSBE group (17.0 6 1.8 vs. 16.7 6 2.3 p=0.9, 2.7 6 0.1 vs. 2.6 6 0.1 p = 0.4 and 46.4 6 5.3 vs. 46.3 6 6.7 p=1.0, respectively). However, duration of heartburn symptom was significantly longer in the LSBE group as compared to the SSBE group (31.0 6 3.0 vs. 24.5 6 2.2, p<0.05). 38 (81%) of SSBE patients and 34 (83%) of LSBE patients reported regurgitation. There was no significant difference in the duration, frequency, severity and intensity of regurgitation symptom between patients with SSBE and those with LSBE (p=0.4, p=0.9, p=0.3 and p=0.6, respectively). No difference in the prevalence and symptom characteristics of nocturnal GERD symptoms, chest pain and dysphagia was found between the two BE groups. Conclusion: Duration of heartburn symptom is the sole symptom characteristic that distinguishes between patients with LSBE (higher risk for esophageal cancer) and those with SSBE (lower risk for esophageal cancer).
VOLUME 59, NO. 5, 2004