Prevalence of intestinal metaplasia in the distal oesophagus, oesophagogastric junction and gastric cardia in symptomatic patients in north-east Italy: a prospective, descriptive survey

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Abstract

Background. Incidence of adenocarcinoma of distal oesophagus and gastric cardia, probably arising from areas of intestinal metaplasia, has been increasing rapidly.

Aims. To define prevalence of intestinal metaplasia of distal oesophagus, oesophagogastric junction and gastric cardia and to evaluate potential associated factors, by means of a prospective multicentre study including University and teaching hospitals, and primary and tertiary care centres.

Patients. Each of 24 institutions involved in study enrolled 10 consecutive patients undergoing first-time routine endoscopy for dyspeptic symptoms.

Methods. Patients answered symptom questionnaires and underwent gastroscopy. Three biopsies were taken from distal oesophagus, oesophago-gastric junction and gastric cardia, and were stained with haematoxylin and eosin. Specimens were also evaluated for Helicobacter pylori infection.

Results. A total of 240 patients (124 male, 116 female; median age 56 years, range 20–90) were enrolled in study. Intestinal metaplasia affected distal oesophagus in 5, oesophago-gastric junction in 19 and gastric cardia in 10 patients. Low-grade dysplasia was found at distal oesophagus and/or oesophago-gastric junction of 324 patients with intestinal metaplasia vs 2216 without intestinal metaplasia (p<0.05). A significant association was found between symptoms and presence of intestinal metaplasia, regardless of location, and between Helicobacter pylori infection and intestinal metaplasia at oesophago-gastric junction.

Conclusions. Intestinal metaplasia of distal oesophagus, oesophagogastric-junction and gastric cardia is found in a significant proportion of symptomatic patients undergoing gastroscopy and is associated with dysplasia in many cases. Although prevalence of dysplasia seems to decrease when specialized columnar epithelium is found in short segment, or even focally in oesophago-gastric junction, these small foci of intestinal metaplastic cells may represent source of most adenocarcinomas of cardia.

References (25)

Cited by (25)

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    The most recent American College of Gastroenterology guideline on Barrett’s esophagus (BE) states that IM of cardia is found in up to 20% of asymptomatic patients who undergo endoscopy.1,2 It also states that the presence of IM cardia is similar in patients with BE and controls1,3 and that IM cardia is associated with Helicobacter pylori.1,4 These conclusions are based on studies that were published more than 17 years ago when the use of high-definition white-light endoscopy (HDWLE) and electronic chromoendoscopic imaging were not routine and do not appear to have been used in these studies.

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    In addition, intestinal metaplasia is common in the gastric cardia and a complete intestinal metaplasia is more often associated with Helicobacter pylori infection. However, there is not an increased risk of esophageal adenocarcinoma as seen with incomplete IM, which may benefit from further surveillance for progression to dysplasia.19 The Prague classification is a validated and reliable system for describing segments consistent with BE.20

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    IM of the cardia is common in the general population and can be seen in up to 20% of asymptomatic individuals.14 To date, the natural history of IM at the GEJ is thought to be different than that of the tubular esophagus, as it is more likely to be associated with Helicobacter pylori infection and not with EAC.14–16 As such, biopsy of a normal or slightly irregular GEJ found incidentally during an endoscopy for GERD is not recommended.17

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    As a result, the recommended number of random biopsy samples is 4 for every 2 cm of BE segment length or 8 for segment length <2 cm in those with suspected BE.28 In addition, a normal or mildly irregular Z-line should not call for routine biopsy, because IM of the cardia is common in patients with chronic GERD,29 and chronic GERD has not been definitively demonstrated to imply an increased risk of EAC.30,31 In terms of BE classification, a segment >3 cm is defined as long-segment BE, and a segment <3 cm is defined as short-segment BE.

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