Esôfago de Barrett: o estado da arte / Barrett's Esophagus: the state of the art

Objetivo: Demonstrar fatores envolvidos nos distúrbios do sono em profissionais que fazem plantões. Métodos: Trata-se de estudo transversal, cuja amostra foi composta de 244 voluntários, plantonistas da área da saúde, sendo 191 do sexo feminino, que responderam a um questionário socioeconômico, associado à aplicação da Escala de Sonolência de Epworth e ao Índice de Qualidade do Sono de Pittsburgh. Os dados foram analisados pelos coeficientes de Spearman e de Kendall Tau, com distribuição de probabilidade gama. Resultados: Houve significância (p<0,05) com o Índice de Qualidade do Sono de Pittsburgh e a atividade física (+0,216), ergonomia (+0,148), filhos (-0,146), valor da remuneração (+0,112) e disfunção durante o dia (+0,352). Também houve significância com a Escala de Sonolência de Epworth e atividade física (+0,138), renda familiar (-0,118), trabalho semanal (-0,151), latência do sono (-0,106), duração do sono (-0,107), eficiência do sono (-0,139) e disfunção durante o dia (+0,170). Por fim, a eficiência do sono teve significiância com profissão (-0,209), tabagismo (+0,402), Escala de Sonolência de Epworth (-0,139) e dissonias com a obesidade (índice de massa corporal >30; razão de chance de 1,40; intervalo de confiança de 95% de 1,02-1,94). Conclusão: As medidas autorrelatadas são prontamente obtidas com questionários validados, como a Escala de Sonolência de Epworth e o Índice de Qualidade do Sono de Pittsburgh, encontrando-se correlações com renda familiar, ter ou não filhos, índice de massa corporal, atividade física, ergonomia, condições de trabalho, tabagismo e componentes biopsicossociais. Em virtude do caráter transversal deste estudo é indispensável mais estudos com maior follow-up

Objective: To demonstrate factors involved in sleep disorders in professionals who take shifts. Methods: This is a cross-sectional study whose sample consists of 244 volunteers, on-duty health workers, 191 females, who answered a socioeconomic questionnaire, associated with application of the Epworth Sleepiness Scale and the Pittsburgh Sleep Quality Index. Data were analyzed with Spearman's and Kendall Tau coefficients, and gamma probability distribution. Results: There was significance (p<0,05) with the Pittsburgh Sleep Quality Index and physical activity (+0,216), ergonomics (+0,148), children (-0,146), the wage (+0,112), dysfunction during the day (+0,352). Also there was significance with the Epworth Sleepiness Scale and physical activity (+0,138), family income (-0,118), weekly workload (-0,151), sleep latency (-0,106), sleep duration (-0,107), sleep efficiency (-0,139), and dysfunction during the day (+0,170). Finally, sleep efficiency was significant with occupation (-0,209), smoking habits (+0,402), Epworth Sleepiness Scale (-0,139), dyssomnia with obesity (body index mass >30; OR of 1,40; CI 95% 1,02-1,94). Conclusion: Self-reported measures are readily obtained with validated questionnaires such as Epworth Sleepiness Scale and Pittsburgh Sleep Quality Index, with correlations with family income, having children or not, body mass index, physical activity, ergonomics, working conditions, smoking habits, and biopsychosocial components. Due to the cross-sectional nature of this study, further research with longer follow-up is indispensable

Metagenomic analysis of the gastric microbiota cultivable from a patient with gastritis concomitant with Barrett´s esophagus / Análisis metagenómico de la microbiota gástrica cultivable a partir de un paciente con gastritis concomitante con esófago de Barrett

Barrett’s esophagus is a distal metaplasia characterized by the transformation of squamous mucosa into columnar mucosa. This esophageal phenotype is a product not only of the chronic reflux of gastric acids, but also by microorganisms that colonize the oral cavity and stomach. Two classes of microbiota can be identified in Barrett’s esophagus; microbiota type I is associated with the normal esophagus and type II with an inflamed esophagus. The present study describes the gastric microbiota of a patient with antral gastritis concomitant with Barrett’s esophagus absent infection with Helicobacter pylori. Gastric biopsies were obtained following the protocol of Sydney and following ethical practices. The isolates were cultivated under microaerophilic conditions on Columbia Agar supplemented with IsoVitaleX™ and 7% sterile blood. Extracted DNA was sequenced using 454-GS and the results analyzed on the MG-RAST server. Gram negative isolates were found and bacteria resistant to levofloxacin, amoxicillin, tetracycline, erythromycin, and clarithromycin. The phyla Bacteroidetes, Firmicutes, Fusobacteria and Proteobacteria, the genus Bacteroides and the species group Bacteroides fragilis were most abundant. Functionally, the metabolism of carbohydrates, amino acids, and to a lesser extent, the metabolism of cofactors and vitamins were most dominant, and of which the enzymes β-glucosidase (EC 3.2.1.21), β-galactosidase (EC 3.2.1.23) and β-N-acetylhexosaminidase (EC 3.2.1.52) were most dominant. The findings of this study, because they are of only one case may probably suggest a possible pathogenic role, previously undescribed for Bacteroides fragilis, associated with human gastritis when concomitant esophageal pathology exists.

El esófago de Barrett es una metaplasia distal caracterizada por la transformación de la mucosa escamosa a mucosa columnar. Este fenotipo esofágico es producto no solo de la exposición crónica al reflujo de ácidos gástricos sino también a microbios colonizantes de la cavidad oral y del estómago. El esófago Barrett presenta 2 clases de microbiotas; la microbiota tipo I asociada con esófago normal y la tipo II a fenotipos esofágicos inflamatorios. En el presente estudio se describió la microbiota gástrica de una paciente con gastritis antral concomitante con esófago de Barrett sin infección por Helicobacter pylori y se obtuvieron biopsias gástricas siguiendo el protocolo de Sydney y estándares bioéticos. Los cultivos se hicieron en condiciones microaerofílicas en agar Columbia suplementados con isovitalex y sangre estéril al 7%. El ADN extraído fue sometido a secuenciación empleando 454 GS y las lecturas fueron analizadas en el servidor MG-RAST. Se obtuvieron aislamientos gram-negativos y resistentes a levofloxacina, amoxicilina, tetraciclina, eritromicina y claritromicina. Los Phylum Bacteroidetes, Firmicutes, Fusobacteria y Proteobacteria, el género Bacteroides y las especies de grupo Bacteroides fragilis fueron los más abundantes. Funcionalmente, el metabolismo de carbohidratos, aminoácidos y en menor grado el metabolismo de cofactores y vitaminas fueron los más dominantes; de los cuales las enzimas la β-glicosidasa (EC 3.2.1.21), β-galactosidasa (EC 3.2.1.23) y la β-N-acetilhexosaminidasa (EC 3.2.1.52) fueron las más dominantes. Estos resultados, por ser de un solo caso, solo podrían sugerir un posible papel patogénico no descrito para Bacterioides fragilis asociado con gastritis humana cuando existe patología esofágica concomitante.

Barrett's Esophagus and Cancer Risk: How Research Advances Can Impact Clinical Practice

Barrett's esophagus (BE) is the only known precursor to esophageal adenocarcinoma (EAC), whose incidence has increased sharply in the last 4 decades. The annual conversion rate of BE to cancer is significant, but small. The identification of patients at a higher risk of cancer therefore poses a clinical conundrum. Currently, endoscopic surveillance is recommended in BE patients, with the aim of diagnosing either dysplasia or cancer at early stages, both of which are curable with minimally invasive endoscopic techniques. There is a large variation in clinical practice for endoscopic surveillance, and dysplasia as a marker of increased risk is affected by sampling error and high interobserver variability. Screening programs have not yet been formally accepted, mainly due to the economic burden that would be generated by upper gastrointestinal endoscopy. Screening programs have not yet been formally accepted, mainly due to the economic burden that would be generated by widespread indication to upper gastrointestinal endoscopy. In fact, it is currently difficult to formulate an accurate algorithm to confidently target the population at risk, based on the known clinical risk factors for BE and EAC. This review will focus on the clinical and molecular factors that are involved in the development of BE and its conversion to cancer and on how increased knowledge in these areas can improve the clinical management of the disease.

What is the rea impairment on esophageal motilty in patients with gastroesophhageal reflux disease?

Context Impairment of esophageal motility is a common finding in patients with gastroesophageal reflux disease (GERD) as reduced lower esophageal sphincter (LES) basal pressure. A very low LES pressure might facilitate the occurrence of more gastroesophageal reflux whereas abnormal esophageal peristalsis may contribute to impaired esophageal clearance after reflux. Objective Evaluate the esophageal motor function of the lower esophageal sphincter and esophageal body in the various forms of gastroesophageal reflux disease. Methods The manometrics records of 268 patients, who had evaluation of the esophageal motility as part of the diagnostic gastroesophageal reflux disease were split into four groups, as follows: 33 patients who had no esophagitis; 92 patients who had erosive esophagitis; 101 patients who had short Barrett's esophagus and 42 patients who had long Barrett's esophagus. Results The group who had long Barrett's esophagus showed smaller mean LES pressure and higher percentage of marked LES hypotonia; in the distal segment of the esophageal body the this group showed higher percentage of marked hypocontractility of the distal segment (<30 mm Hg); this same group showed higher percentage of esophageal motility disorders. Conclusions The most intense esophageal motility disorders and lower pressure of lower esophageal sphincter were noted in the group with long Barrett's esophagus. Those with reflux esophagitis and short Barrett's esophagus had esophageal motility impairment, intermediate among patients with esophagitis and long Barrett's esophagus. Patients with typical symptoms of gastroesophageal reflux but without esophagitis by endoscopy study showed no impairment of esophageal motility. .

Contexto Alteração no peristaltismo esofágico assim como diminuição do tônus basal do esfíncter inferior do esôfago são um achado comum em pacientes com doença do refluxo gastroesofágico. A presença de hipotonia acentuada do esfíncter inferior do esôfago pode facilitar a ocorrência de refluxo gastroesofágico mais intenso e a presença de alteração no peristaltismo esofágico pode contribuir para uma deficiente depuração esofágica. Objetivo Avaliar a função motora do esfíncter inferior do esôfago e do corpo esofágico nas várias formas da doença do refluxo gastroesofágico. Métodos Avaliaram-se os prontuários de 268 pacientes, que realizaram manometria esofágica como parte da investigação diagnóstica da doença do refluxo gastroesofágico. Os pacientes foram distribuidos em quatro grupos: 33 pacientes que não tinham esofagite, 92 pacientes que tinham esofagite erosiva; 101 pacientes que tinham esôfago de Barrett curto e 42 pacientes que tinham esôfago de Barrett longo (grupo EBL). Resultados O grupo dos que tinham EBL, apresentou menor média de pressão do esfíncter inferior do esôfago e maior percentual de hipotonia acentuada do esfíncter inferior do esôfago; no segmento distal do corpo do esôfago, este grupo apresentou maior percentual de hipocontratilidade acentuada (< 30 mm Hg). O grupo dos que tinham EBL apresentou maior porcentagem de distúrbios da motilidade esofágica. Conclusões As alterações mais intensas na motilidade esofágica e no esfíncter inferior do esôfago foram observadas no grupo com EBL. Aqueles com esofagite de refluxo e esôfago de Barrett curto ...

prevalence of obstructive sleep apnea characteristics in patients with Barrett's esophagus

An increasing number of patients with Barrett's espophagus present for diagnostic and/or therapeutic upper GI endoscopy. It has been our impression that a large number of these patients have history and characteristics strongly suggestive of obstructive sleep apnea [OSA], and are, therefore, more challenging to sedate during the upper GI endoscopic procedures. This study was conducted to prospectively quantify the prevalence of OSA characteristics in patients with Barrett's esophagus. Consented patients with Barrett's esophagus were prospectively screened for obstructive sleep apnea [OSA] risk using the modified neck circumference questionnaire. The study demonstrated a statistically significant association between Barrett's esophagus and high OSA risk when compared to the general GI endoscopy population

Esôfago de Barrett progride para câncer em apenas 0, 12% por ano nos cinco primeiros anos / Barretts esophagus progresses to cancer at only 0.12% per year over the first five years

Os resultados1 encontraram taxa muito baixa de progressão para o câncer entre os pacientes que têm esôfago de Barrett. Aalta taxa de detecção durante o primeiro ano após o diagnósticoda metaplasia sugere uma possível utilidade em se repetir aendoscopia em seis meses ou um ano. Mas a predisposição paraa vigilância generalizada e permanente de todos os pacientescom esôfago de Barrett deve ser ponderada à luz desses achados epidemiológicos.

Metaplasia intestinal en esófago: diagnóstico con magnificación endoscópica y “flexible spectral imaging colour enhancement” (FICE) corroborado por histología / Intestinal metaplasia in esophagus: diagnosis With magnifying endoscopy and flexible Spectral imaging colour enhancement (fice) Corroborated by histology

La endoscopia estándar no identifica esófago de Barrett. Esta limitación disminuye con magnificación endoscópica, coloración vital y/o virtual que permite observar los patrones de mucosa sugestivos de metaplasia intestinal. Identificar metaplasia intestinal con magnificación endoscópica y cromoscopia virtual realizada con "Flexible Spectral Imaging Colour Enhancement" (FICE) corroborándola con histología. Pacientes: Previo consentimiento se incluyeron a los individuos con indicación electiva de endoscopia digestiva superior. Se realizó endoscopia digestiva superior con equipo Fujinon Inc. EG 590 ZW, y procesador EPX 4400. Consecutivamente se practicó endoscopia con: a) alta resolución, b) FICE, c) alta resolución, d) magnificación, e) FICE y f) alta resolución. Cada patrón encontrado se grabó, se fotografió y se guardó en JPEG en programa Power Point. Los patólogos evaluaron la biopsia del patrón observado sin tener datos del paciente. Se incluyeron 30 pacientes: 11 hombres y 19 mujeres con rango de edad 20-83 años y promedio 51,73 años. Solo con magnificación sola o con cromoscopia virtual se observaron los patrones de mucosa. En el tipo 3 se diagnosticó esófago de Barrett en 33,33% y en ninguno de los otros. Conclusión: La magnificación endoscópica y cromoscopia virtual con FICE identifica metaplasia intestinal y diagnostica esófago de Barrett

Standard endoscopy does not identify Barrett's esophagus or mucosa patterns suggestive of intestinal metaplasia. Endoscopic magnification, vital and or virtual chromoscopy reduces this limitation. Aim: Identify intestinal metaplasia with endoscopic magnification and Flexible Spectral Imaging Colour Enhancement (FICE) corroborating it with histology. Patients: Individuals scheduled to undergo routine upper gastrointestinal endoscopy were enrolled. Upper gastrointestinal endoscopy was performed with Fujinon Inc. 590 EG ZW and EPX 4400 processor. Endoscopy was consecutively performed with: a) high resolution, b) FICE, c) high resolution, d) magnification, e) FICE, f) high resolution. Each found pattern was recorded, was photographed and was saved in JPEG in program Power Point. Biopsy was obtained of the predominant pattern and the pathologist assessed without patient information. Results: 30 patients were included, 11 men and 19 women with 20-83 years and 51.73 years average age range. Patterns of mucosa were observed only with magnification and virtual chromoscopy, Barrett's esophagus was diagnosed in 33.33% of type 3 and none in type 1 and 2. The endoscopic magnification and virtual chromoscopy with FICE identifies intestinal metaplasia and let diagnose Barrett's esophagus.

Esophageal manometry findings and degree of acid exposure in short and long Barrett's esophagus / Alterações manométricas e intensidade do refluxo no esôfago de Barrett curto e longo

CONTEXT: Barrett's esophagus (BE) is characterized by intestinal metaplasia in the distal esophagus and is classified as short-segment (<3 cm - SSBE) or long-segment (>3 cm - LSSBE). It is suggested that LSSBE is associated with more severe esophageal motor abnormalities and increased acid exposure time than SSBE. OBJECTIVE: To evaluate the prevalence of esophageal manometriy abnormalities and acid exposure times in patients with SSBE and LSSBE. METHODS: Barrett's esophagus patients identified by upper endoscopy and confirmed by histopathology were, retrospectively, reviewed and divided into two groups: SSBE and LSBE. Demographic data, symptom duration, prevalence of hiatal hernia, lower esophagus sphincter basal pressure, prevalence of esophageal body abnormalities and acid exposure times were evaluated. RESULTS: Forty-six patients with SSBE (24 males - 52.2%, mean age of 55.2 years) and 28 patients with LSBE (18 males - 64.3%, mean age of 50.5 years). Mean symptom duration was 9.9 years for SSBE and 12.9 years for LSSBE. Hiatal hernia was present in 84.2% of SSBE, 96.3% of LSBE; average lower esophagus sphincter pressure in SSBE 9.15 mm Hg, in LSBE 6.99 mm Hg; lower esophagus sphincter hypotension in SSBE was 65.9%, in LSSBE 82.1%; aperistalsis in SSBE 6.5%, LSSBE 3.6%; mild/moderate ineffective esophageal motility in SSBE 34.8%, LSBE 46.4%; severe moderate ineffective esophageal motility in SSBE 10.9%, LSBE 7,1%; nutcracker esophagus/segmental nutcracker esophagus in SSBE 8.6%, LSBE 0%; normal body in SSBE 39.1%, in LSBE 42.9%, no statistical difference for any of these values (P<0.05). Average % total time pH<4 in SSBE 9.12, LSBE 17.27 (P<0.000); % time pH<4 upright in SSBE 11.91; LSBE 24.29 (P=0.003); % time pH<4 supine in SSBE 10.86, LSBE 33.26 (P = 0.000). CONCLUSION: There was no difference between the prevalence of motor disorders in patients with SSBE and LSSBE. Acid reflux in upright and supine positions was more intense in LSBE.

CONTEXTO: O esôfago de Barrett (EB) se caracteriza pela presença de metaplasia intestinal no esôfago distal, quando menor que 3 cm é chamado Barrett curto (EBC) e com 3 cm ou mais Barrett longo (EBL). Sugere-se que o EBL cursa com mais alterações motoras esofagianas e com refluxo mais intenso que o EBC. OBJETIVO: Avaliar a prevalência de alterações manométricas e a intensidade do refluxo gastroesofágico à pHmetria em pacientes com EBC e EBL. MÉTODOS: Estudo retrospectivo de pacientes com endoscopia digestiva alta e comprovação histopatológica de EB, divididos em dois grupos: EBC e EBL. Foram avaliados os dados demográficos, o tempo de doença, prevalência de hérnia hiatal, dados obtidos à esofagomanometria e pHmetria. RESULTADOS: EBC 46 pacientes (24 masculino 52,2% e média de idade de 55,22 anos), EBL 28 pacientes (18 masculino 64,3% e média de idade 50,5 anos); tempo de sintomas: EBC 9,88 anos e EBL 12,94 anos; hérnia de hiato: EBC 84,2%, EBL 96,3%; pressão média do esfíncter inferior do esôfago: EBC 9,15 mm Hg, EBL 6,99 mm Hg; hipotensão do esfíncter inferior do esôfago: EBC 65,9%, EBL 82,1%; motilidade esofagiana ineficaz (MEI) leve/moderado: EBC 34,8%, EBL 46,4%; MEI acentuado: EBC 5 10,9%, EBL 7,1%; aperistalse: 6,5%, EBL 3,6%; esôfago em quebra-nozes: EBC 8,6%, EBL 0%; corpo normal: EBC 39,1%, EBL 42,9%, sem diferença estatística para qualquer desses valores (P<0,05). Médias de pHmetria: % de tempo total com pH <4: EBC (29/46) 9,12% EBL (15/28) 27,27% P<0,000; % de tempo ereto com pH<4: EBC 11,91%, EBL 24,29% P = 0,003; % de tempo supino com pH <4: EBC 10,86% EBL 33,26% P = 0,000. CONCLUSÕES: Não houve diferença entre a prevalência das alterações motoras em pacientes com EBC e EBL. O refluxo ácido, tanto em posição ereta como em posição supina, foi mais intenso no EBL.

Updated Guidelines 2012 for Gastroesophageal Reflux Disease / 대한소화기학회지

In 2010, a Korean guideline for the management of gastroesophageal reflux disease (GERD) was made by the Korean Society of Neurogastroenterology and Motility, in which the definition and diagnosis of GERD were not included. The aim of this guideline was to update the clinical approach to the diagnosis and management of GERD in adult patients. This guideline was developed by the adaptation process of the ADAPTE framework. Twelve guidelines were retrieved from initial queries through the Appraisal of Guidelines for Research & Evaluation II process. Twenty-seven statements were made as a draft and revised by modified Delphi method. Finally, 24 consensus statements for the definition (n=4), diagnosis (n=7) and management (n=13) of GERD were developed. Multidisciplinary experts participated in the development of the guideline, and the external review of the guideline was conducted at the finalization phase.

The Prevalence of Barrett's Esophagus and the Comparison of Barrett's Esophagus with Cardiac Intestinal Metaplasia in the Health Screening at a Secondary Care Hospital / 대한소화기학회지

BACKGROUND/AIMS: The purpose of this study was to estimate the prevalence of Barrett's esophagus (BE) and its association with reflux esophagitis (RE) and peptic ulcer disease detected by free charge endoscopy which was covered by the National Health Insurance at a secondary care hospital, and to compare the results of the biopsy of BE with that of cardiac intestinal metaplasia (CIM). METHODS: A total of 4,002 patients underwent endoscopy from March 2010 to December 2012. BE was diagnosed if there was histologically proven specialized intestinal metaplasia, and CIM was diagnosed if intestinal metaplasia was accompanied with chronic gastritis. RESULTS: Four hundred twenty four patients underwent endoscopic biopsy, and the prevalence of BE was 1.0% (42/4,002). The mean age and the proportion of males in BE were significantly higher than those of the rest of study population, and BE had slight tendency related to RE than the rest of study population. CIM was observed in 34 patients and BE and CIM showed similar results, regarding age, sex and association with RE. The mean length of endoscopic Barrett's mucosa of BE group was 9.2+/-5.1 mm, and it was similar to that of CIM. CONCLUSIONS: The prevalence of BE in the secondary care hospital was not low, and old age and male sex were significantly associated with BE. Because BE was observed in about 10% of biopsied patients and CIM was observed in a similar percentage with BE, the precise targeted biopsy is warranted and the biopsy method should be reestablished through the large prospective study of multiple secondary care hospitals.

Clinical Characteristics of Gastroesophageal Reflux Disease with Esophageal Injury in Korean: Focusing on Risk Factors / 대한소화기학회지

BACKGROUND/AIMS: Recent studies suggest that the prevalence of gastroesophageal reflux disease (GERD) is increasing in Korea. However, studies on risk factors for GERD have yielded inconsistent results. The aims of this study were to compare clinical features between symptomatic syndromes without esophageal injury (=non-erosive disease [NED]) and syndromes with esophageal injury (=erosive disease [ED]), and to determine risk factors associated ED. METHODS: A total of 450 subjects who visited gastroenterology clinics of six training hospitals in Daegu from March 2008 to April 2010 were consecutively enrolled. The subjects were asked to complete a questionnaire which inquired about gastroesophageal reflux symptoms. The questionnaire also included questions about smoking, alcohol drinking, consumption of coffee, use of drugs, exercise, and other medical history. The subjects were subdivided into NED and ED groups. RESULTS: The proportion of subjects in each NED and ED group was 172 (38.2%) and 278 (61.8%). Male gender, smoking, alcohol drinking, consumption of coffee, large waist circumference, infrequent medication of antacids, aspirin and NSAIDs, infrequent and mild GERD symptoms were all significantly associated with ED on univariate analysis. Age, hiatal hernia, diabetes mellitus, body mass index, change in weight during 1 year, and number of typical GERD symptoms were not independent risk factors for ED. However, the association between ED and alcohol drinking, infrequent medication of antacids, mild typical GERD symptoms remained as strong risk factors after adjustments on multivariate logistic analysis. CONCLUSIONS: Independent risk factors associated with ED were alcohol drinking, infrequent medication of antacids and mild typical GERD symptoms.

A inter-relação das sialomucinas (antígenos Tn e Stn) com o adenocarcinoma no esôfago de Barrett / Relationship of the sialomucins (Tn and Stn antigens) with adenocarcinoma in Barrett's esophagus

OBJETIVO: O esôfago de Barrett (EB) é conseqüência do refluxo gastroesofágico crônico e considerado fator de risco para o desenvolvimento de adenocarcinoma. Estudos do muco, em especial das mucinas ácidas representadas pelas sialomucinas presentes nas células caliciformes, mostraram que na metaplasia do tipo intestinal, o epitélio do órgão pode expressar antígenos denominados Tn e Stn. Estes antígenos já foram analisados em tumores gástricos e colônicos, porém não foram encontradas referências à sua utilização no EB. Este trabalho objetivou analisar estes antígenos em doentes com EB e em adenocarcinoma associado ao EB. MÉTODOS: Foram estudados, utilizando testes imunohistoquímicos, os antígenos Tn e Stn, nas biópsias endoscópicas de 29 doentes com EB, sete com adenocarcinoma no EB, além de oito indivíduos com epitélio esofágico normal. RESULTADOS: Nas células caliciformes, foi observada positividade para Stn em 100 por cento dos casos e para Tn em 48 por cento dos casos. Nas células colunares, o Stn foi sempre negativo, enquanto o Tn foi positivo em 100 por cento dos casos. Entretanto, nos doentes com adenocarcinoma no EB, a positividade para ambos os antígenos foi de 100 por cento. Nos indivíduos normais, houve positividade para o antígeno Tn e negatividade para Stn em todos os casos (100 por cento). CONCLUSÃO: É provável que nos doentes com EB a positividade para o Tn, à semelhança do ocorrido quanto à positividade do mesmo antígeno nos portadores de adenocarcinoma, possa significar maior suscetibilidade para ocorrência futura de câncer. Assim, a pesquisa das sialomucinas poderá ser rotineiramente utilizada, contribuindo como fator prognóstico para desenvolvimento de adenocarcinoma no EB.

OBJECIVE: Barrett's esophagus (BE) is a consequence of chronic gastroesophageal reflux and is considered a risk factor for adenocarcinoma. The study of the mucus, especially acid mucins, such as the sialomucins in the goblet cells which characterize BE, showed that in intestinal metaplasia, frequent in the digestive tract, the organ's original epithelium could express Tn and Stn antigens. These antigens have already been detected in gastric and colonic tumors, however references in BE were not found. This research aimed to analyze these antigens in patients with BE and in adenocarcinoma associated with BE. METHODS: Utilizing immunohistochemistry tests, Tn and Stn antigens were studied in the endoscopic biopsies of 29 patients with BE and seven with adenocarcinoma in BE, as well as eight individuals with normal esophageal epithelium at upper digestive endoscopy.. RESULTS: The Stn antigen was positive in the goblet cells of patients with BE in 100 percent of the cases and the Tn was positive in 48 percent. In the columnar cells, Stn was always negative, while Tn was positive in 100 percent of the cases. However, in adenocarcinoma in BE, both antigens were 100 percent positive. In normal individuals, the Tn antigen was positive and the antigen Stn negative in all cases. CONCLUSION: It is probable that the BE group in which the Tn antigens in the goblet cells are positive, similarly to the same antigen in the adenocarcinoma group, might indicate a higher susceptibility for potential occurrence of cancer. In the future, trials with sialomucins could be used routinely, thereby contributing as a prognostic factor of adenocarcinoma in BE.

Quimioprevención en adenocarcinoma de esófago / Chemoprevention in adenocarcinoma of the esophagus

The incidence of the adenocarcinoma of the esophagus (ACE) has dramatically for the last decades in western countries, which has been associated with a parallel increase in the incidence and prevalence of symptoms associated with gastroesophageal reflux diseases (GERD) and Barrett's esophagus (BE). Both conditions are now considered risk factors for ACE. Different pathways, including overexpression of cyclooxygenase (COX) isoenzymes, has been proposed to explain the carcinogenic process leading from normal esophagus to esophagitis, BE and ACE. The survival rate in patients with ACE is very low because of the poor outcomes of surgery and the limited benefits obtained with concomitant chemo-radiotherapy Several strategies based on early detection and surveillance of preneoplastic lessions have failed to have a global and significant impact on the prognosis of the ACE. Recent epidemiological and experimental studies suggest that chemoprevention could be useful in the management of patients with GERD and especially in those with BE. The current therapy with protom pump inhibitors (PPI) is effective to reduce the esophageal acid exposure, to improve reflux symptoms, and to heal inflammatory injuries, but probably is not enough to avoid the dysplastic progression of the metaplastic epithelium. Regular use of COX inhibitors (aspirin and other non steroid antiinflamatory drugs) has been associated with reduction of the risk of ACE and to decrease the incidence of ACE in animal models. In humans, the association of PPI with COX inhibitors could be a cost-effectiveness strategy but direct evidence is lacking. Other potential agents that have shown some chemoprevention potential include troglitazone, free radical scavengers, tamoxifen or prostaglandin receptor blockers, but the available scientific evidence is still poor and not ready to be tested in humans.

El adenocarcinoma de esófago (ACE) ha aumentado notablemente su incidencia en las últimas décadas, en los países occidentales; lo que se ha asociado a un crecimiento paralelo de la incidencia y prevalencia de los síntomas atribuibles a la Enfermedad por Reflujo Gastroesofágico (ERGE) y a un aumento de los diagnósticos de esófago de Barrett (EB). Ambas situaciones sonconsideradas como factores de riesgo para el desarrollo de ACE. Se han propuesto diferentes vías, incluyendola sobreexpresión de los isoenzimas de la ciclooxigenasa (COX), para explicar el proceso de carcinogénesis quetranscurre entre la mucosa esofágica normal, la esofagitis, el EB y el ACE.La tasa de supervivencia en pacientes con ACE es muy baja, debido a los deficientes resultados del tratamientoquirúrgico, así como a los escasos beneficios aportados por la quimio y radioterapia concomitantes. Diversasestrategias basadas en el diagnóstico precoz y seguimiento de las lesiones preneoplásicas han fracasado enconseguir un impacto global y significativo sobre el pronósticodel ACE. Estudios epidemiológicos y experimentales recientes sugierenque la quimioprevención podría ser útil en el manejo de los pacientes con ERGE, y especialmente en aquellos con EB. La terapia convencional con inhibidoresde la bomba de protones (IBP) es eficaz para reducir la exposición ácida esofágica, mejorar los síntomas por el reflujo y curar las lesiones inflamatorias, pero probablemente no es suficiente para evitar la progresión displásica del epitelio con metaplasia. El uso regular de inhibidores de la COX (aspirina y otros antiinflamatoriosno esteroides) es capaz de bloquear vías decarcinogénesis y disminuir la incidencia de ACE en modelos animales. En humanos, la asociación de IBPcon inhibidores de la COX podría ser una estrategia segura y coste-efectiva, aunque no existen evidencias directasque lo corroboren. En lo que respecta a...

Esófago de Barrett: estado actual del tratamiento quirúrgico / Barrett Esophagus: present status of the surgical management

El esófago de Barrett (EB) es una complicación de la enfermedad por reflujo gastroesofágico, yse define como el esófago inferior recubierto de epitelio columnar con metaplasia intestinal producto del reflujo crónico... El objetivo de esta comunicación es desarrollar el estado actual del tratamiento quirúrgico en pacientes con EB respecto de: el control del reflujo, su efecto sobre la metaplasia intestinal y en la prevención del adenocarcinoma

Esófago de Barrett: actualización del tratamiento endoscópico / Barrett's esophagus: update of the endoscopic treatment

El manejo actual del esófago de Barrett incluye el tratamiento de los síntomas de enfermedad por reflujo gastroesofágico, la prevención del daño erosivo y la vigilancia endoscópica para detectar la progresión a displasia de alto grado y adenocarcinoma esofágico. Ante la presencia de displasia de alto grado y cáncer superficial, se han intentado terapias menos invasivas, alternativas a la cirugía resectiva, como el Argon Plasma Coagulator, Electrocoagulación Multipolar, Heater Probe, asociados o no a cirugía antirreflujo, la Terapia Fotodinámica y en los últimos años la ablación endoscópica por radiofrecuencia o BARREx. Se vislumbran además como terapias de destrucción del epitelio de Barrett actualmente en estudio la terapia ultrasónica y la crioterapia. La Resección Mucosa Endoscópica del epitelio de Barrett, procedimiento con potencial curativo, es además la única técnica que permite el análisis histopatológico del tejido. En la presente revisión analizaremos los resultados obtenidos con las diferentes terapias endoscópicas actuales y en desarrollo para el esófago de Barrett.

Actual Barrett’s esophagus management includes symptomatic approach for GERD in order to prevent erosive injury, and endoscopic & histologycal surveillance to detect dysplasia and early cancer. In high-grade dysplasia and superficial carcinoma, less aggressive procedures has been attempted to avoid extended surgery, such as Argon Plasma Coagulator, Multipolar Coagulation, Heater Probe, Photodynamic Therapy, and recently radiofrequency local treatment, associated or not to antireflux surgery. Ultrasonic therapy and Cryotherapy are new approaches, which are under clinical investigation. Barrett’s epithelium resection utilizing endoscopical mucosal resection is a new promising procedure, which comes to the arena, allowing besides the compromised epithelium removal, its complete pathological evaluation and probably a curative intent. The actual revision intents to discuss the results of the different alternatives at the platform of treatment in dysplastic Barrett’s or early carcinoma growing in the Barrett’s epithelium.

Esófago de Barret sin displasia: mucosectomía endoscópica / Barrett's esophagus without displasia: endoscopic mucosectomy

En general, con estas técnicas mínimamente invasivas de resección endoscópica del epitelio de Barrett o del carcinoma intramucoso, se logra una remisión local en un 90 por ciento, con baja morbilidad, sin mortalidad, dejando un esófago in situ y funcional.

Citoqueratinas 7 y 20 en el esófago de Barrett / Cytokeratina 7 and 20 in Barrett's esophagus

El esófago de Barrett (EB) es un factor de riesgo conocido para el desarrollo de adenocarcinoma esofágico. El EB ha sido categorizado como a segmento largo (EBSL) si se extiende a más de 3 cm de la unión esófago-gástrica, o a segmento corto (EBSC) si se observa mucosa de aspecto columnar a menos de 3 cm de dicha unión. La metaplasia intestinal puede también desarrollarse en la mucosa gástrica (MIG) de la unión esófago-gástrica. presentando un menor potencial desarrollo de cambios displásicos o adenocarcinomatosos. Estas condiciones son difíciles de distinguir entre sí sólo en base a parámetros endoscópicos o morfológicos. El objetivo de este estudio fue evaluar patrones de inmunomarcación con anticuerpos para citoqueratinas (CQ) 7 y 20 en estas entidades con el fin de identificar el sitio de origen de dichas metaplasias intestinales. Fueron evaluadas 27 biopsias pertenecientes a pacientes con sospecha endoscópica de EBSL y EBSC, las cuales fueron comparadas con biopsias con diagnóstico de MIG. El patrón CQ7/20 de tipo Barrett fue observado en el 100% de los EBSL. el cual no fue identificado en ninguna de las biopsias con MIG. En estas últimas se observó por el contrario la ausencia de marcación con CQ7 y tinción con CQ20 en el epitelio superficial. En el grupo de pacientes con EBSC. 67% presentaron el patrón CQ7/20 tipo Barrett. mientras que e133% restante evidenció una marcación similar a la vista en las biopsias con MIG. Nuestros hallazgos confirman la alta especificidad del patrón Inmunohistoquímico de CQ7/20 para distinguir metaplasias intestinales correspondientes a EBSL o EBSC de las MIG.

Barrett's oesophagus (BE) has been identified as the most important risk factor for adenocarcinoma of the distal oesophagus. BE has been categorized as long-segment (LSBE) if it extends 3 cm or more up the oesophagus and as short segment (SSBE) if it extends less than 3 cm into oesophagus. Intestinal metaplasia may also develop in gastric mucosa (lMG) at the gastroesophagealjunction. IMG has a much lower risk to progress to dysplasia or carcinoma when compared with SLBE or SSBE. Moreover. these conditions are difficult to distinguish one from another only based on endoscopic and morphologic criteria. Therefore the aim this study was to evaluate the cytokeratin (CK) 7 and 20 inmunoreactivity patterns in these intestinal metaplasias with the purpose to determine the precise anatomic site ofthe biopsy. Biopsy specimens from 14 patients with LSBE, 6 with SSBE and 7 patients with IMG were inmunohistochemically stained with monoc1onal antibodies to CK 7 and 20. Barrett's CK7/20 pattern was characterized by superficial and deep CK7 reactivity and only superficial CK 20 staining in the intestinalized mucosa. This pattern was found in all 7 ( I 00%) patients with LSBE, and was absent in all 7 patients with IMG. All biopsy specimens from patients with IMG showed no staining for CK7 and diffuse surface positivity for CK20. 67% of the biopsy specimens from patients with endoscopic SSBE showed Barrett's CK7/20 pattern, and the remaining 33% specimens showed the IMG stainlng pattern. Based on our data the inmunohistochemical determination of CK7/20 is an excelent tool with high specificity in distinguishing LSBE and SSBE from IMG.

Immunohistochemical Expression of the p53 and Ki-67 Proteins in Barrett's Esophagus in Korea / 대한소화기학회지

BACKGROUND/AIMS: Barrett's esophagus is a premalignant lesion of the esophagus in which normal squamous epithelium is replaced by intestinalized columnar epithelium. In Korea, adenocarcinoma associated with Barrett's esophagus is rare compared with that of Western country. The purpose of this study was to investigate the immunohistochemical expression of p53 and Ki-67 in Barrett's esophagus which had predictive value for cancer risk in Korea. METHODS: Ninety five patients (43 male and 52 female, median age 44, range 21-75) who have been suspected to have Barrett's esophagus by endoscopic assessment were enrolled in this study. Alcian blue (pH 2.5) and high ion diamine stain for the evaluation of specialized intestinal metaplasia (SIM) and immunohistochemical stain for p53 and Ki-67 were done. RESULTS: 57.9% (55/95) of biopsies from the columnar lined esophagus showed SIM, but no dyspalsia. 56.4% (31/55) of Barrett's esophagus showed sulfomucin positive colonic metaplasia. The p53 expression was observed in 10.9% (6/55) of the patients of Barrett's esophagus and all of them showed colonic metaplasia. Ki-67 labeling index showed no difference significantly. CONCLUSIONS: In Korea, 10.9% of Barrett's esophagus had p53 mutation and moreover all of them had colonic metaplasia. Consequently, we expect that these patients have high risk of developing dysplasia and adenocarcinoma and need careful follow-up.