Allaying uncertainty in diagnosing buried Barrett's esophagus.

Subsquamous intestinal metaplasia (SSIM) in the setting of Barrett's esophagus (BE) is a technically challenging diagnosis. While the risk for progression of BE involving the surface mucosa is well documented, the potential risk for development of advanced neoplasia associated with SSIM has been controversial. This study aimed to determine the effects of specimen adequacy, presence of dysplasia, and interobserver agreement for SSIM interpretation. Adult patients (n = 28) who underwent endoscopic therapy for BE with high-grade dysplasia or intramucosal carcinoma (HGD/IMC) between October 2005 and June 2013 were included. Initial evaluation (n = 140 slides) by an experienced gastrointestinal pathologist was followed by an interobserver study by 8 pathologists. Forty-seven (34%) slides had insufficient subsquamous tissue to assess for SSIM. SSIM was found in 19% of all slides and 29% of slides with sufficient subsquamous tissue. At least one slide had SSIM in 54% to 64% of patients. Subsquamous low grade dysplasia (LGD) was found in 4 (15%) slides with SSIM and subsquamous HGD/IMC was found in 5 (19%) slides with SSIM. At the patient level, 8 (53%) had no dysplasia, 4 (27%) had LGD and 3 (20%) had HGD/IMC. Overall agreement for SSIM by slide was 92% to 94% (κ = 0.73 to κ = 0.82, moderate to strong agreement), and by patient was 82% to 94% (κ = 0.65 to κ = 0.87, moderate to strong agreement). This study confirms the need for assessing specimen adequacy and assessing the prevalence of SSIM and is the first to assess interobserver agreement for SSIM and dysplasia within SSIM.

Clinical Outcomes Based on the Timing of Appearance of Visible Lesions in Barrett's Esophagus During Endoscopic Eradication Therapy.

BACKGROUND AND GOALS: Visible lesions (VLs) in Barrett's esophagus (BE) are seen in 70% to 90% of patients presenting for endoscopic eradication therapy (EET). It is not known if there are any differences in outcomes of patients with flat dysplasia versus patients with VL. Our aim was to assess outcomes of EET in BE patients with VL and BE patients with flat dysplasia. STUDY: This is a single center study with data drawn from a prospective registry of patients referred for EET of BE between 2011 and 2015. Demographic data, endoscopic findings, histologic findings, and response to EET were analyzed. RESULTS: There were 264 patients of which 34 had flat dysplasia, 180 had VL before initiating EET (prevalent lesions) and 50 who developed VL during EET (incident lesions). Compared with patients with flat dysplasia, patients with VL had longer segments of BE (5 vs. 4 cm, P=0.002) and greater prevalence of high-grade dysplasia (HGD) or esophageal adenocarcinoma (EAC) (63.6% vs. 29.4%, P<0.001). Incident lesions are less likely to harbor HGD/EAC compared with prevalent lesions (28.1% vs. 61.8%, P<0.001). There were no significant differences in eradication of metaplasia/dysplasia between the groups. No progression or recurrences were observed in flat dysplasia group. In VL group, 14 patients progressed (prevalent VL=11, incident VL=3) and 15 had recurrences (prevalent VL=11, incident VL=4). CONCLUSIONS: About 19% of BE patients developed VL during EET. There is higher prevalence of HGD/EAC in prevalent VL compared with incident VL. However, the outcomes did not differ.

Cryotherapy and Radiofrequency Ablation for Eradication of Barrett's Esophagus with Dysplasia or Intramucosal Cancer.

BACKGROUND AND AIMS: Endoscopic ablation therapy has become the mainstay of treatment of Barrett's associated dysplasia and intramucosal cancer (IMC). The widely available techniques for ablation are radiofrequency ablation (RFA) and cryotherapy. Our aim was to compare eradication rates of metaplasia and dysplasia with both these modalities. PATIENTS AND METHODS: Retrospective review of prospectively collected database of patients who underwent endoscopic therapy for Barrett's dysplasia or IMC from 2006 to 2011 was performed. Demographic features, comorbidities, and endoscopic data including length of Barrett's segment, hiatal hernia size, interventions during the endoscopy and histological results were reviewed. RESULTS: Among 154 patients included, 73 patients were in the RFA and 81 patients were in the cryotherapy group. There was complete eradication of intestinal metaplasia (CE-IM) in 81 (52.6%), complete eradication of dysplasia (CE-D) in 133 (86.4%), and persistent dysplasia or cancer in 19 patients (12.3%). Compared to RFA, cryotherapy patients were found to be older and less likely to have undergone endoscopic mucosal resection. On multivariate analysis, patients who underwent RFA had a threefold higher odds of having CE-IM than those who underwent cryotherapy (odds ratio [OR] 2.9, 95% confidence interval [CI] 1.4-6.0, p = 0.004), but CE-D were similar between the two groups (OR 1.7, 95% CI 0.66-4.3, p = 0.28). CONCLUSIONS: Endoscopic therapy is highly effective in eradication of Barrett's associated neoplasia. Patients who underwent cryotherapy were equally likely to achieve CE-D but not CE-IM than patients who underwent RFA. Patient characteristics and preferences may effect choice of treatment selection and outcomes.

Upper esophageal sphincter abnormalities and high-resolution esophageal manometry findings in patients with laryngopharyngeal reflux.

BACKGROUND: The association between laryngopharyngeal reflux (LPR) and abnormalities of upper esophageal sphincter (UES) and esophageal motility is not clearly known. High-resolution esophageal manometry (HREM) has allowed accurate measurement and evaluation of UES and esophageal function. GOALS: To evaluate the UES function and esophageal motility using HREM in patients with LPR and compare them to patients with typical gastroesophageal reflux disease (GERD). STUDY: All patients evaluated for GERD or LPR symptoms with esophageal function testing including HREM, ambulatory distal pH monitoring and upper endoscopy between 2006 and 2014 were retrospectively studied (n = 220). The study group (group A, n = 57) consisted of patients diagnosed with LPR after comprehensive evaluation. They were compared to patients who had typical GERD symptoms only (group B, n = 98) and patients with both GERD and LPR symptoms (group C, n = 65). RESULTS: Abnormalities in UES pressures and relaxation were found in about one-third of patients in all groups. There were no significant differences between the groups. Group B had higher prevalence of abnormal esophageal motility compared to others (group A vs. B vs. C = 20.8% vs. 28% vs. 12.5%, p = .029). Group B patients also had higher prevalence of Barrett's esophagus compared to others (group A vs. B vs. C = 0% vs.12.2% vs. 4.6%, p = .01). Distal pH testing revealed no significant differences between the three groups. CONCLUSIONS: Abnormal UES function was noted in one-third of patients with LPR or GERD. However, there were no abnormalities on esophageal function testing specific for LPR.

Influence of body mass index on the prevalence and progression of dysplasia in Barrett's esophagus: a retrospective analysis (.).

OBJECTIVE: High body mass index (BMI) is a risk factor for Barrett's esophagus (BE) and esophageal adenocarcinoma (EAC). Our aim was to determine if prevalence of dysplasia in BE varies by BMI and study the effect of BMI on progression to high-grade dysplasia (HGD) or EAC. MATERIALS AND METHODS: This is a retrospective review of patients with endoscopic evidence of BE confirmed by presence of intestinal metaplasia on histology from January 2000 to December 2012 at Cleveland Clinic. Patient demographics, BMI and endoscopic findings such as length of BE, dysplasia in BE and size of hiatal hernia were reviewed. Dysplasia was classified as no dysplasia (NDBE), low-grade dysplasia (LGD), HGD and EAC. RESULTS: In this cohort of 1239 patients, average BMI was 29.8 ± 6 kg/m(2). There were 228 (18.4%) in group with BMI <25, 236 (19%) in BMI group 25-27.4, 262 (21.1%) in BMI 27.5-29.9, 303 (24.5%) in BMI 30-34.9, 126 (10.2%) in BMI 35-39.9 and 86 (6.8%) in BMI ≥40. Lower BMI groups had lower prevalence of dysplasia while higher BMI groups had higher prevalence of dysplasia (p = 0.002). During mean follow up of 31.6 ± 26 months, there were 14 cases of HGD/EAC in NDBE group and 29 cases of HGD/EAC in LGD group. BMI or BMI change was not associated with progression to HGD/EAC in NDBE. CONCLUSIONS: High BMI was associated with higher prevalence of dysplasia in BE. But once in a surveillance program, higher BMI is not associated with progression of dysplasia in NDBE.

Lack of incremental effect of histamine receptor antagonists over proton pump inhibitors on the risk of neoplastic progression in patients with Barrett's esophagus: a cohort study.

OBJECTIVE: Long-term acid suppression reduces the risk of progression to esophageal adenocarcinoma (EAC) in patients with Barrett's esophagus (BE). Given recent reports about the harmful effects of using chronic proton pump inhibitors (PPI) there is renewed interest in alternative methods of acid suppression. Hence, we studied the effect of H2 receptor antagonists (H2 RA) on the risk of progression to neoplasia in our BE cohort. METHODS: This is a retrospective analysis of prospectively collected data of patients in our BE registry from 2002 to 2015. Patients' characteristics, endoscopic findings, such as the length of BE, hiatal hernia size and histological findings and patients' use of medications such as PPI, aspirin, H2 RA, metformin and antihyperlipidemic agents were studied. RESULTS: The cohort consisted of 1466 patients with a mean age of 61 ± 13 years. The patients had a predominance of male sex (76.7% [1118/1457]) and Caucasian race (96.6% [1209/1252]). After excluding prevalent high-grade dysplasia (HGD) or EAC, 1025 patients had a median follow up of 43.6 months during which 57 patients progressed to HGD or EAC. PPI use (56% in progressors vs 69% in non-progressors; P = 0.007) but not H2 RA use (12% progressors vs 19% in non-progressors P = 0.162) was associated with lower risk of neoplastic progression. On multivariate analysis, there was no synergistic effect of addition of H2 RA to PPI on risk of neoplastic progression to HGD or EAC (relative risk 0.33; confidence intervals 0.05-2.29, P = 0.262). CONCLUSION: H2 RA do not seem to have a chemopreventive role in patients with BE.