Sanjay Nandurkar

Short segment Barrett's oesophagus: prevalence, diagnosis and associations.

BACKGROUND: Prevalence of short segment Barretts (SSB) oesophagus, defined as the absence of macroscopic Barretts but histologically identifiable intestinal metaplasia, has been reported to be 18% based on haematoxylin and eosin (H&E) staining. AIMS: To define the prevalence of SSB oesophagus using H&E and alcian blue staining and to determine whether SSB oesophagus is associated with inflammation at the gastro-oesophageal junction (GOJ). SUBJECTS: Consecutive patients (n = 158) presenting for endoscopy completed a structured interview. METHODS: Two biopsy specimens taken from the GOJ were stained with H&E, alcian blue and Giemsa. A third specimen was obtained from the distal oesophagus. Intestinal metaplasia was diagnosed if goblet cells were definitely identified by two independent observers. RESULTS: SSB oesophagus was present in 46 (prevalence 36%, 95% confidence interval (CI) 28.5-43.5) using alcian blue staining. If H&E had been the sole staining method used, 50% cases of intestinal metaplasia would have been overlooked. There were no cases of intestinal metaplasia identified by H&E but missed by alcian blue staining. Logistic regression analysis identified age (odds ratio (OR) per decade 1.03, 95% CI 1.01-1.06), histological oesophagitis (OR 3.2, 95% CI 1.4-7.2) and inflammation at the gastrooesophageal junction (OR 5.9, 95% CI 2.2-15.6) as independent risk factors for SSB oesophagus. CONCLUSION: Unrecognised SSB oesophagus is highly prevalent in patients presenting for diagnostic upper endoscopy if alcian blue staining is applied.

Asia-Pacific consensus on the management of gastroesophageal reflux disease: update.

Background and Aims:  Since the publication of the Asia‐Pacific GERD consensus in 2004, more data concerning the epidemiology and management of gastroesophageal reflux disease (GERD) have emerged. An evidence based review and update was needed.

Relationship between body mass index, diet, exercise and gastro-oesophageal reflux symptoms in a community

Background : Body mass index (BMI) is a risk factor for gastro‐oesophageal reflux but may simply be explained by diet and lifestyle.

Report of the Asia-Pacific consensus on the management of gastroesophageal reflux disease.

This report summarizes the conclusions and recommendations of a panel of gastroenterologists practising in the Asia–Pacific region. The group recognized that although gastroesophageal reflux disease (GERD) is less common and milder in endoscopic severity in Asia than in the West, there is nevertheless data to suggest an increasing frequency of the disease. During a 2‐day workshop, the evidence for key issues in the diagnosis and clinical strategies for the management of the disease was evaluated, following which  the  recommendations  were  made  and  debated.  The  consensus  report  was  presented  at  the Asia–Pacific Digestive Week 2003 in Singapore for ratification. Upper gastrointestinal (GI) endoscopy is the gold standard for the diagnosis of erosive GERD. There is no gold standard for the diagnosis of non‐erosive GERD (NERD). Diagnosis therefore relies on symptoms, a positive 24‐h pH study or a response to a course of proton pump inhibitor (PPI) treatment. The goals of treatment for GERD are to heal esophagitis, relieve symptoms, maintain the patient free of symptoms, improve quality of life and prevent complications. The PPI are the most effective medical treatment. Following initial treatment, on‐demand therapy may be effective in some patients with NERD or mild (GI) erosive esophagitis. Anti‐reflux surgery by a competent surgeon could achieve a similar outcome, although there is an operative mortality of 0.1–0.8%. The decision is dependent on the patients preference and the availability of surgical expertise. Currently, endoscopic treatment should be performed only in the context of a clinical trial. Treatment of patients with typical GERD symptoms without alarm features in primary care could begin with PPI for 2 weeks followed by a further 4 weeks before going to on‐demand therapy.

Regression of Barrett's esophagus: the role of acid suppression, surgery, and ablative methods☆☆☆★

Barrett’s esophagus is a condition in which the squamous mucosa that lines the distal esophagus is replaced by a specialized columnar epithelium.1 The label Barrett’s esophagus traditionally was applied to columnar epithelium that extended 3 cm or more above the gastroesophageal junction.2 However, the definition of Barrett’s esophagus has been appropriately broadened to include specialized columnar epithelium containing goblet cells above the gastroesophageal junction regardless of the extent.3 Barrett’s esophagus is important only because of its association with complicated GERD, that is, strictures or ulcers,4,5 and an increased risk for esophageal adenocarcinoma.6 The incidence of adenocarcinoma of the esophagus is increasing rapidly.7-13 This increase in esophageal adenocarcinoma has occurred in relation to esophageal squamous cancer and in absolute terms. From 1926 to 1976, four large surgical series showed that only 0.8% to 3.7% of esophageal cancers were adenocarcinoma.6 In later surgical series with patients seen between 1979 and 1992, 54% to 68% of cancers were adenocarcinoma.6 These clinical observations are supported by population-based studies from around the world.7-13 Blot et al.7 analyzed data from the National Cancer Institute Surveillance, Epidemiology, and End Results program that covered approximately 10% of the U.S. population. They reported that the increasing incidence of esophageal adenocarcinoma was greater than for any other cancer in the United States. The same trend has been observed in Australia and New Zealand.14-16 It is generally recommended that patients with Barrett’s esophagus be enrolled into a lifelong endoscopic and histologic surveillance program for the detection of dysplasia and cancer.17,18 However, regular surveillance is very expensive19,20 and the cost effectiveness of this approach has been questioned.21-24 Induction of regression of Barrett’s epithelium is theoretically an attractive alternative because it may eliminate the cancer risk and hence the need for surveillance programs. We performed a systematic review to analyze the feasibility of using different modalities to induce regression of Barrett’s esophagus.

A prospective open clinical trial of a proton pump inhibitor, elimination diet and/or budesonide for eosinophilic oesophagitis.

Elimination diets and high‐dose proton pump inhibitors (PPI) are advocated as first‐line treatments in patients with eosinophilic oesophagitis (EoE).

Rates of Endoscopy and Endoscopic Findings among People with Frequent Symptoms of Gastroesophageal Reflux in the Community

BACKGROUND:Epidemiological studies have confirmed that gastroesophageal symptoms are highly prevalent. However, studies linking epidemiology with clinical or chart data are scarce. We aimed to determine the frequency of endoscopy and endoscopic findings, as well as predictors of health-care utilization, among people with reflux symptoms in the community.METHODS:A previous survey of 2,118 Olmsted County, MN, residents in 1993 identified 242 subjects with frequent reflux symptoms (at least weekly) who received care at a medical center in the county. Data were abstracted from Mayo Clinic records between 1988 and 1998.RESULTS:Overall, 130 of the 242 (54%, 95% CI 47–60%) had sought care for reflux. Twenty-five patients (10%) had visited a gastroenterologist; 47 (19%) had an upper endoscopy (EGD), 64 (26%) had an upper GI X-ray, and one had an ambulatory 24-h esophageal pH study. Long segment Barretts esophagus was detected in 4 (9%) of those having an EGD and adenocarcinoma was found in one patient with Barretts. Three patients had surgery for gastroesophageal reflux disease. Thirteen patients (5%) died, but no deaths were due to esophageal reflux or adenocarcinoma. Age, higher education, frequent heartburn, and dysphagia were all significant, independent predictors of consulting.CONCLUSIONS:Although many people in the community have frequent reflux symptoms, few have investigations, and deaths were unrelated to reflux disease or its complications. Data from referral clinic or endoscopy series should not be extrapolated to the large numbers of people in the community with symptoms of reflux.

Allergy tests do not predict food triggers in adult patients with eosinophilic oesophagitis. A comprehensive prospective study using five modalities

The use of allergy tests to guide dietary treatment for eosinophilic oesophagitis (EoE) is controversial and data are limited. Aeroallergen sensitisation patterns and food triggers have been defined in Northern Hemisphere cohorts only.

Seasonal recurrence of food bolus obstruction in eosinophilic esophagitis

Eosinophilic esophagitis (EoE) is a newly recognised condition that is apparently increasing in prevalence, and the aetiology is poorly understood. The role of aeroallergens in EoE is controversial, given the success of dietary therapy. Massive aeroallergen exposure leading to food bolus obstruction events (FBOE) has been described, and the diagnosis of EoE by esophageal biopsy noted to be more common in the pollen season according to previous case series.

Eosinophilic esophagitis: a clinicopathological review.

Eosinophilic esophagitis (EoE) is considered to be a chronic antigen-driven disease whereby food and/or aeroallergens induce a chronic inflammatory infiltrate in the esophagus, resulting in pathological hyperplasia of the epithelia and muscular layers, and fibrosis of the lamina propria (referred to collectively as remodelling) and the symptoms of dysphagia and food impaction. EoE shares features with other atopic conditions of asthma and atopic dermatitis, such as a TH2 cytokine milieu and a mixed inflammatory infiltrate of eosinophils, mast cells and lymphocytes. Relatively distinct features include the strong male predominance amongst adult patients, and the expression of the eosinophil chemokine eotaxin 3. Current first line treatments such as strict dietary modification and corticosteroids fail many patients. Looking forward, clarification of distinct genotype/phenotype associations, determining the reversibility of remodelling following treatment, and the development of new pharmacotherapies that target fibrotic pathways (as opposed to eosinophilic inflammation per se) or specifically improve barrier integrity appear relevant.