The incidence of distal esophageal adenocarcinoma is rising and chronic reflux and Barrett’s esophagus are both considered risk factors.
At present, reliable detection of Barrett's esophagus dictates the use of upper endoscopy, but both endoscopy and histology are required for accurate confirmation.
Appropriate management of patients with endoscopic suspicion but with negative histology,or of patients with no endoscopic suspicion but with a biopsy diagnosis of intestinal metaplasia at the gastro-esophageal junction, has not yet been studied prospectively.
Researchers from The University of Munich in Germany carried out a prospective multicenter study in which a total of 929 patients (51% male, mean age 50 years) referred for upper gastrointestinal endoscopy were included.
59% of these patients had reflux symptoms.
Researchers noted the endoscopic aspect of the Z line and any suspicion of Barrett’s esophagus. Biopsies were then taken in all patients from the Z line (n = 4), gastric cardia (n = 2), and body and antrum (n = 2 each).
| Only 10–20% of cases with either endoscopic or histological suspicion of Barrett’s esophagus had established Barrett's after 2.5 years of follow up|
A reference pathologist reviewed cases in which biopsies were found positive for specialized intestinal metaplasia (SIM) for confirmation of a final Barrett’s esophagus diagnosis.
All patients with endoscopic and/or histological suspicion of Barrett’s esophagus were invited for a follow up endoscopy; the remaining cases (no endoscopic or histological suspicion of Barrett’s esophagus) were followed clinically.
Of the total 235 patients positive for Barrett’s esophagus on endoscopy and/or histology, 63% agreed to undergo repeat endoscopy.
46% of patients with an endoscopic Barrett’s esophagus diagnosis but no histological confirmation showed the same distribution.
A further 42% did not have Barrett’s esophagus, and 11% had confirmed Barrett’s esophagus on both endoscopy and biopsy on follow up.
In the group with a histological Barrett’s esophagus diagnosis who had no findings on initial endoscopy, follow up showed the same in 26% whereas 46% had no Barrett’s esophagus.
Confirmed Barrett’s esophagus (endoscopy plus histology) was diagnosed in 17% of these patients.
Of the study population, 16 patients had Barrett’s esophagus on initial endoscopy confirmed by histology which remained constant in 70% at follow up.
Of the remaining patients without an initial Barrett’s esophagus diagnosis on either endoscopy or histology and only clinical follow up, one confirmed Barrett’s esophagus case was found among 100 patients re-endoscoped outside of the study protocol.
However, no single case of dysplasia or cancer of the distal oesophagus was detected in any patient during the study period.
Professor Rosch commented,"Even in a specialised gastroenterology setting, reproducibility of presumptive endoscopic or histological diagnoses of Barrett’s oesophagus at follow up were poor."
In addition, "Only 10–20% of cases with either endoscopic or histological suspicion of Barrett’s oesophagus had established Barrett’s oesophagus after 2.5 years of follow up."
The group concluded that meticulous follow up may not be required as the risk of dysplasia in this population was shown to be very low.