GERD or gastrointestinal reflux disease is the most common cause of esophagitis. This is heartburn or dysphagia that is experienced after a large meal. The symptoms are usually pain, a sour taste in the mouth, and occasionally vomiting blood (hematemesis) or blood in the stools (melena). There are several mechanisms all leading to the esophagus exposed to the acidic gastric juices leading to injury.
This is a disease usually present in adults over 40 years although cases in infants and children have been reported. The importance of diagnosing and treating the disease are the complications which may result. Bleeding and pain have been mentioned. However, with time, reflux esophagitis may lead to Barrett esophagus, a significant risk factor for adenocarcinoma of the esophagus.
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EPIDEMIOLOGY CHARACTERIZATION SYNONYMS Reflux Esophagitis INCIDENCE
The impact of upper GI endoscopy referral volume on the diagnosis of gastroesophageal reflux disease and its complications: a 1-year cross-sectional study in a referral area with 260,000 inhabitants.
Mantynen T, Farkkila M, Kunnamo I, Mecklin JP, Juhola M, Voutilainen M.
Karstula Health Care Center, Finland.
Am J Gastroenterol 2002 Oct;97(10):2524-9 Abstract quote
OBJECTIVES: Less than half of patients with gastroesophageal reflux disease (GERD) have endoscopic erosive esophagitis (endoscopy positive GERD). Symptomatic GERD and Barrett's esophagus (BE), however, are risk factors for esophageal and gastric cardia adenocarcinomas. The aim of the present study was to examine the prevalence of GERD-related findings on endoscopy according to the volume of referrals to upper GI endoscopy.
METHODS: The following data were gathered on all GERD patients who were sent for upper GI endoscopy by general practitioners (GPs) during 1 yr in our hospital referral area of 260,000 inhabitants: the number of referrals to endoscopy in health care units, and the numbers of endoscopy positive GERD, BE, and esophageal neoplasms. Patients with symptoms or signs suggesting acute upper GI bleeding and those attending follow-up endoscopy (e.g., for BE, peptic ulcer, or dysplasia) were excluded, as were patients with previous esophagogastric surgery or Helicobacter pylori eradication therapy.
RESULTS: The study population consisted of 3378 patients, with a mean age of 58.1 yr (95% CI = 57.5-58.6) and a male:female ratio of 1:1.3. Of the 760 patients who underwent endoscopy because of heartburn or regurgitation, 254 (33.4%) had endoscopy positive (erosive) GERD, 11 (1.4%) BE (one with esophageal adenocarcinoma), six (0.8%) esophageal ulcer, and one peptic esophageal stricture (0.1%). Between health care units, the referrals to endoscopy (number of endoscopies/population/yr) varied from 0.6 to 9.2/1000 inhabitants/yr (median 3.3/1000/yr). In health care units with "high" referral volumes (> or = 3.3 referrals/1000/yr, N = 15, 1297 patients) and "low" referral volumes (< 3.3/1000/yr, N = 15, 2081 patients), the numbers of endoscopy positive GERD were 281 (21.7%) versus 308 (14.9%, p < 0.001), esophageal ulcer 13 (1.0%) versus 14 (0.7%, p = 0.3), esophageal stricture five (0.4%) versus seven (0.3%, p = 0.4), Barrett's esophagus eight (0.6%) versus 16 (0.8%, p = 0.6), and esophageal neoplasm two (0.2%) versus six (0.3%, p = 0.2). Five of the neoplasms were squamous cell carcinomas, two were adenocarcinomas, and one was lymphoma. Multivariate analyses showed that independent risk factors for endoscopy positive GERD were male sex (OR = 1.4, 95% CI = 1.2-1.7), GERD symptoms (OR = 3.3, 95% CI = 2.7-4.0), dysphagia (OR = 1.4,95% CI = 1.0-2.1), and living in a high referral area (OR = 1.4, 95% CI = 1.2-1.7). Independent risk factors for BE were male sex (OR = 2.6, 95% CI = 1.1-6.1) and GERD symptoms (OR = 2.9, 95% CI = 1.3-6.6), whereas the only independent risk factor for esophageal neoplasm was dysphagia (OR = 40.0 (95% CI = 7.7-207.5).
CONCLUSIONS: There is a wide variation in GPs' referrals for endoscopy. Increasing the referral volume significantly increases the proportion of endoscopy positive GERD cases, but not that of GERD complications such as BE, esophageal ulcer, peptic stricture, or esophageal neoplasms.
Obesity and estrogen as risk factors for gastroesophageal reflux symptoms.
Nilsson M, Johnsen R, Ye W, Hveem K, Lagergren J.
Department of Surgery, Karolinska Institutet, Karolinska Hospital, Stockholm, Sweden
JAMA. 2003 Jul 2;290(1):66-72. Abstract quote
CONTEXT: Gastroesophageal reflux and obesity are both increasing in prevalence. The scientific evidence for an association between these conditions is sparse and contradictory. A difference between sexes concerning this relation has been proposed.
OBJECTIVE: To evaluate the relation between body mass and gastroesophageal reflux symptoms and determine how this relation is influenced by female sex hormones.
DESIGN: Population-based, cross-sectional, case-control study.
SETTING: Two consecutive public health surveys within the county of Nord-Trondelag, Norway, conducted in 1984-1986 and 1995-1997.
PARTICIPANTS: Among 65 363 adult participants in the second survey, 3113 individuals who reported severe heartburn or regurgitation during the last 12 months were defined as cases, whereas 39 872 persons without reflux symptoms were defined as controls.
MAIN OUTCOME MEASURE: Risk of reflux, estimated using multivariate logistic regression, with odds ratios (ORs) and 95% confidence intervals (CIs) as measures of association.
RESULTS: There was a dose-response association between increasing body mass index (BMI) and reflux symptoms in both sexes (P for trend <.001), with a significantly stronger association in women (P<.001). Compared with those with a BMI less than 25, the risk of reflux was increased significantly among severely obese (BMI >35) men(OR, 3.3; 95% CI, 2.4-4.7) and women (OR, 6.3; 95% CI, 4.9-8.0). The association between BMI and reflux symptoms was stronger among premenopausal women compared with postmenopausal women (P<.001), although use of postmenopausal hormone therapy increased the strength of the association (P<.001). Reduction in BMI was associated with decreased risk of reflux symptoms.
CONCLUSIONS: There is a significant association between body mass and symptoms of gastroesophageal reflux. The association is stronger among women, especially premenopausally, and use of hormone therapy strengthens the association, suggesting that estrogens may play an important role in the etiology of reflux disease.
DISEASE ASSOCIATION CHARACTERIZATION HELICOBACTER PYLORI
Reflux esophagitis facilitates low Helicobacter pylori infection rate and gastric inflammation.
Jang TJ, Kim NI, Suh JI, Yang CH.
Department of Pathology, Dongguk University College of Medicine, Kyongbuk, Korea.
J Gastroenterol Hepatol 2002 Aug;17(8):839-43 Abstract quote
BACKGROUND: Helicobacter pylori is regarded as an important pathogen in upper gastrointestinal diseases. However, little is known about the relationship between H. pylori infection and reflux esophagitis. Therefore, an investigation was undertaken in Korean subjects regarding the incidence of H. pylori infection, and a histopathological study of reflux esophagitis was also carried out.
METHODS: Analysis of gastric biopsy specimens was conducted for 73 patients with reflux esophagitis and 132 control subjects without reflux esophagitis. The H. pylori infection was assessed by using rapid urease test and the immunohistochemical method, and gastric mucosal morphologic change was analyzed according to the updated Sydney system.
RESULTS: The prevalence of H. pylori infection was significantly lower in patients with reflux esophagitis than in the non-reflux group. Grade of inflammation and glandular atrophy in the antrum and body were higher in patients in the non-reflux group compared with those in the reflux esophagitis group.
CONCLUSIONS: It is suggested that H. pylori infection decreases the risk of reflux esophagitis by inducing atrophic gastritis.
PATHOGENESIS CHARACTERIZATION Mechanism Disorders Decreased efficiency of the lower esophageal sphincter tone
Systemic sclerosing disorders
Alcohol and tobacco
Mechanical Sliding hiatal hernia Decreased gastric or small bowel motility Mass or neuromuscular disorders of the musculature
Histology of the Gastroesophageal Junction An Autopsy Study
Parakrama T. Chandrasoma, M.D., M.R.C.P.; Roger Der, M.D.; Yanling Ma, M.D.; Patricia Dalton, M.D.; Mark Taira, M.D.
From the Department of Surgical Pathology (P.T.C., R.D., Y.M., P.D.), Los Angeles County, University of Southern California Medical Center; and the Los Angeles County Department of Coroner (M.T.), Los Angeles, CA, U.S.A.
Am J Surg Pathol 2000;24:402-409 Abstract quote
Current diagnostic criteria for reflux disease and Barrett's esophagus are based on the belief that the gastroesophageal junction normally contains 2 cm of cardiac mucosa composed of mucous glands devoid of parietal cells.
This autopsy study disproves this belief. Even when the entire circumference of the gastroesophageal junction is examined, pure cardiac mucosa was completely absent in 56% of patients. All patients had oxyntocardiac mucosa, in which glands contained a mixture of mucous and parietal cells. Cardiac and oxyntocardiac mucosae were present only in part of the circumference of the junction in 50% of patients. The measured maximum length of cardiac plus oxyntocardiac mucosa was less than 0.5 cm in 76% of patients. There was a tendency for the presence and extent of cardiac mucosa to increase with age.
Cardiac mucosa at the junction is therefore frequently absent, has considerable individual variation, is very small in extent when present, is commonly absent from some part of the circumference of the junction, and increases in prevalence and length with age. These characteristics of cardiac mucosa make it highly unlikely that it is a normal structure.
We develop the hypothesis that cardiac mucosa represents an early histologic manifestation of gastroesophageal reflux.
HISTOLOGICAL TYPES CHARACTERIZATION General Basal zone hyperplasia greater than 20% of the epithelial thickness, elongation of the lamina propria papillae to the upper third of the thickness of the epithelium, and inflmmatory cells especially eosinophils, neutrophils, and lymphocytes within the epithelium.
- Is there a set of histologic changes that are invariably reflux associated?
Takubo K, Honma N, Aryal G, Sawabe M, Arai T, Tanaka Y, Mafune K, Iwakiri K.
Human Tissue Research Group, Tokyo Metropolitan Institute of Gerontology, Sakae-cho 35-2, Itabashi-ku, Tokyo 173-0015, Japan.
Arch Pathol Lab Med. 2005 Feb;129(2):159-63. Abstract quote
Many histologic changes have been described in the esophageal squamous mucosa in patients with gastroesophageal reflux disease (GERD), including dilated intercellular spaces, balloon cells, intrapapillary vessel dilation, elongated papillae, basal cell hyperplasia, acanthosis, intraepithelial eosinophils, Langerhans cells, and p53 protein overexpression.
To define a set of histologic changes that are invariably reflux associated, we examined the histologic changes in esophageal specimens from normal controls, patients with GERD, patients without GERD but with a suspicion of other pathology, and patients with esophageal carcinoma. We also examined biopsy specimens from sites with differing endoscopic features, including cloudy white and reddened mucosa. A definitive set of reflux-associated histologic changes could not be defined from the small number of biopsy specimens examined in the present study.
Histologic changes indicative of GERD are likely to be found somewhere in the esophagus in all patients with GERD, but these changes are nonspecific. A set of histologic changes that are invariably reflux associated may exist, but these changes are nonspecific.
To develop a set of characteristic reflux-associated features, endoscopists may perform targeted biopsies from several sites with various endoscopic features and at different stages of disease.
Definition of Histopathologic Changes in Gastroesophageal Reflux Disease
Parakrama T. Chandrasoma, M.D.; Dilani M. Lokuhetty, M.D.; Tom R. Demeester, M.D.; Cedric G. Bremner, M.D.; Jeffrey H. Peters, M.D.; Stefan Oberg, M.D.; Susan Groshen, Ph.D.
From the Departments of Surgical Pathology (P.T.C., D.M.L.) and Surgery (T.R.D., C.G.B., J.H.P., S.O.), University of Southern California School of Medicine; and the Department of Preventive Medicine (S.G.), University of Southern California, Los Angeles, CA, U.S.A.
Am J Surg Pathol 2000;24:344-351 Abstract quote
A series of 71 patients with multiple measured biopsies of the gastroesophageal junctional region permitting assessment of the presence and length of different glandular epithelial types is presented.
All but nine of 53 patients in whom a 24-hour pH study was performed had abnormal reflux, suggesting that endoscopic recognition of an abnormal columnar mucosa at the gastroesophageal junction sufficient to precipitate multiple-level biopsies indicates a high probability of abnormal reflux.
All patients had cardiac mucosa (CM) or oxyntocardiac mucosa (OCM). CM was present in 68 of 71 patients. The prevalence of intestinal metaplasia increased with increasing CM+OCM length, and was present in all 22 patients with a CM+OCM length >2 cm and in 20 of 49 patients with a CM+OCM length <2 cm. Patients with a CM+OCM length >2 cm had a markedly higher acid exposure than patients with a CM+OCM length <2 cm. The findings suggest that the presence of CM and OCM in the junctional region are predictive of abnormal acid exposure, and that increasing OCM+CM length correlates strongly with the amount of acid exposure.
The histologic finding of CM and OCM represents a sensitive histologic criterion for gastroesophageal reflux rather than normal epithelia. These diagnostic criteria represent the first useful histologic definitions for assessing the presence and severity of reflux.
Gastric cardia intestinal metaplasia: biopsy follow-up of 85 patients.
Goldstein NS. Department of Anatomic Pathology, William Beaumont Hospital, Royal Oak, Michigan 48073, USA.
Mod Pathol 2000 Oct;13(10):1072-9 Abstract quote
BACKGROUND: Gastric cardia intestinal metaplasia (CIM), denoted by goblet cells is common. The frequency of persistent CIM is unknown.
METHODS: 85 patients with CIM and follow-up endoscopies were prospectively identified during the time period of 10/6/94-12/21/97. The presence of goblet cells was the defining feature of CIM, other metaplastic cell types were not evaluated. AU 85 patients initially had biopsies that straddled the squamocolumnar junction (SCJ) showed CIM, an otherwise normal proximal stomach, lower esophagus, and squamocolumnar junction. The SCJ lay within the 2 cm of mucosa immediately proximal to the uppermost gastric fold and overlaid the junction of the tubular esophagus and the saccular dilatation of the stomach in all patients. The patients underwent endoscopy for many reasons. They were randomly identified based on the absence of a hiatal hernia and the presence of CIM.
RESULTS: Ten of the 85 patients had CIM on repeat biopsy. Among patients with no CIM in the first repeat endoscopy, the degree of cardia inflammation decreased between the initial and first repeat endoscopy, whereas there was no change in the amount of inflammation among patients who had CIM in the first repeat endoscopy. The changes in mean inflammation score was significantly different between the two groups (P = .024). Twenty-two patients underwent a second repeat endoscopy and five had a third repeat endoscopy. Including all follow-up biopsies, six of the 85 patients (7%) had CIM. Four patients who did not have CIM on initial repeat endoscopy had CIM on their second repeat endoscopy, probably reflecting sampling issues. None of the biopsies had dysplasia.
CONCLUSIONS: Cardia inflammation is a stimulus for cardia intestinal metaplasia, and a reduction in inflammation may allow the metaplastic mucosa to revert to normal.
Gastric cardia inflammation and intestinal metaplasia: associations with reflux esophagitis and Helicobacter pylori.
Goldstein NS, Karim R.
Department of Anatomic Pathology, William Beaumont Hospital, Royal Oak, Michigan 48073-6769, USA.
Mod Pathol 1999 Nov;12(11):1017-24 Abstract quote
Gastric cardia inflammation and intestinal metaplasia are the subjects of recent investigation. Some authors have found associations with gastroesophageal reflux disease, whereas others have identified relationships with Helicobacter pylori (HP).
We studied 150 consecutive patients who underwent upper endoscopy, had normal gastroesophageal anatomy, and had biopsies of the antrum, cardia, and lower esophagus, to evaluate relationships between reflux esophagitis, cardia inflammation, intestinal metaplasia, and HP gastritis.
Forty-two patients had HP infection. Cardia inflammation was significantly related to esophageal squamous inflammation in the non-HP-infected patient group and to antral inflammation and cardia HP infection in the HP-infected patient group. The differences between the patient groups was most apparent in the patients with moderate or marked inflammation. Twenty-seven percent of patients had cardia intestinal metaplasia that was related to cardia inflammation.
Cardia inflammation and intestinal metaplasia probably have multiple causes. Pathologists should refrain from applying the term Barrett's esophagus for biopsies procured from the cardia that show intestinal metaplasia in patients with a normal squamocolumnar junction.
Carditis: A Manifestation of Gastroesophageal Reflux Disease
Am J Surg Pathol 2001;25:245-252
141 patients in whom cardiac mucosa (CM) was present in biopsy samples from the gastroesophageal junctional region
Inflammation of CM, irrespective of its exact anatomic location, was defined as carditis and classified as acute or chronic based on the number of inflammatory cells present
In all cases, CM showed significant chronic inflammation
111 (79%) of the 141 patients with carditis showed no evidence of gastritis in biopsy samples from the gastric antrum and body
Helicobacter pylori was present in 20 of 141 (14%) patients:
17 had evidence of a pangastritis
15 of these patients also showing H. pylori in CM
Patients with severe chronic inflammation in CM had a significantly higher acid exposure of the lower esophagus as quantitated by a 24-hour pH test than those with mild chronic inflammation in CM
Acute inflammation was uncommon in CM:
Present in only 26 of 141 (18.4%)
No significant difference in acid exposure of the lower esophagus between patients with and without acute inflammation in CM
Acute inflammation in CM was significantly associated with distal gastritis and H. pylori infection
Men with carditis had quantitatively higher acid exposure of the lower esophagus than did women with this disorder
Difference was greatest in men with severe inflammation in CM who had no evidence of distal gastritis
Chronic inflammation in CM is strongly associated with acid reflux and that H. pylori is not a significant etiologic factor in carditis
Patients with CM in whom H. pylori gastritis develops, the infection frequently spreads to involve CM, resulting in acute inflammation with neutrophils that is superimposed on the chronic inflammation already present
Histological score for cells with irregular nuclear contours for the diagnosis of reflux esophagitis in children.
Esposito S, Valente G, Zavallone A, Guidali P, Rapa A, Oderda G.
Hum Pathol. 2004 Jan;35(1):96-101 Abstract quote.
Histological criteria for the diagnosis of reflux esophagitis include basal zone hyperplasia, stromal papillae elongation, and inflammatory infiltrate. However, endoscopic esophageal biopsy specimens may include little or no lamina propria. Intraepithelial T lymphocytes, seen in hematoxylin and eosin-stained sections as cells with irregular nuclear contours (CINC), may have a higher density in children with esophagitis.
We evaluated the diagnostic accuracy of a numerical score built up by grading the "classical" parameters and its correlation with CINC density in grasp biopsy specimens obtained from children undergoing esophagogastroduodenoscopy with and without esophagitis.
We analyzed esophageal biopsy specimens from 349 children (median age, 5 years) subdivided in 4 groups according to the previous routine histology report: group 1, 144 children with esophagitis; group 2, 65 controls; group 3, 51 children with dubious esophagitis; and group 4, 75 children with esophagitis on endoscopy but a normal histology report. A numerical value was assigned to each parameter; the sum of these values represented the histological score. We also evaluated intraepithelial CINC density (ie, number of CINC per high-power field). We separately analyzed histological sections with and without lamina propria. For both total score and for CINC density, we calculated a cutoff using a receiver operating characteristic curve. Cutoffs of 6 for score and of 4 for CINC density provided the best sensitivity and specificity.
Sensitivity of the histological score was better in biopsy specimens containing lamina propria (94%) than in those without lamina propria (4%). Sensitivity of CINC density was satisfactory in both specimens with (78%) and without (75%) lamina propria. Specificity was satisfactory for both parameters.
In conclusion, when lamina propria was present in sections of endoscopic esophageal biopsy specimens, histological score provided a better diagnostic accuracy for the diagnosis of esophagitis. However, when no lamina propria was present, as was the case in 67% of our children, CINC density had better sensitivity. In addition, this latter parameter showed esophageal mucosa damage in 34% of previously dubious cases or cases with esophagitis at endoscopy but a previous routine histology report of normal mucosa.
DIFFERENTIAL DIAGNOSIS KEY DIFFERENTIATING FEATURES EOSINOPHILIC ESOPHAGITIS
J Pediatr Surg. 2004 Feb;39(2):e4-7. Abstract quote
BACKGROUND/PURPOSE: Children presenting with persistent symptoms attributed to gastroesophaeal reflux disease (GERD) that are unresponsive to both medical and surgical therapies are commonly submitted to esophageal biopsies, the results of which show an abnormal presence of eosinophils. In this setting, eosinophilic esophagitis may be the correct diagnosis. The purpose of this report is to clarify the importance of esophageal eosinophilic infiltration, regardless of whether associated with acid reflux, ie, as an independent symptomatic entity, when treating a patient with refractory GERD.
METHODS: Two boys, aged 8 and 7 years, had the classic symptoms of GERD. They were treated with antacid without improvement of the esophagic lesions. Subsequent esophageal biopsy results showed marked eosinophilic infiltration. From this moment on, eosinophilic esophagitis started to be considered the main diagnosis.
RESULTS: Although eosinophilic infiltration caused by GERD is very frequently found in esophageal biopsy, in case of refractory drug treatment and microscopic findings of a great number of eosinophils and mast cells, eosinophilic esophagitis must be considered. This disease is better treated with corticoids instead of antacid drugs. It explains the reason some patients do not respond to antacid and surgical treatment and remain symptomatic with esophagic lesions.
CONCLUSIONS: In refractory cases of GERD, eosinophilic esophagitis must be considered before any surgical measure.
PROGNOSIS AND TREATMENT CHARACTERIZATION Gastroesophageal Reflux, Barrett Esophagus, and Esophageal Cancer
Nicholas Shaheen, MD, MPH; David F. Ransohoff, MD
JAMA. 2002;287:1972-1981 Abstract quote
Gastroesophageal reflux disease (GERD) is a risk factor for adenocarcinoma of the esophagus, a rare cancer whose incidence is increasing. Adenocarcinoma may develop from Barrett esophagus, a metaplastic change of the esophageal epithelium from squamous to intestinalized columnar mucosa, which is associated with chronic reflux. Some have recommended that patients with chronic reflux symptoms undergo upper endoscopy to assess for Barrett esophagus and to screen for cancer.
To review the evidence linking GERD and Barrett esophagus to esophageal adenocarcinoma and to examine the utility of upper endoscopy as a screening tool in adenocarcinoma of the esophagus among individuals with GERD.
A MEDLINE search was performed to identify all pertinent English-language reports about GERD, adenocarcinoma, and Barrett esophagus from 1968 through 2001. Reports were of randomized controlled clinical trials if available, case-control data if trials were unavailable, and cohort studies if case-control data were unavailable. Pertinent bibliographies were also reviewed to find reports not otherwise identified.
Study Selection and Data Extraction
Studies were selected by using the search terms gastroesophageal reflux, adenocarcinoma, and Barrett's esophagus, with subheadings for classification, complications, drug therapy, economics, epidemiology, mortality, surgery, and prevention and control. Clinical guidelines for the care of subjects with GERD and Barrett esophagus were retrieved and abstracted.
Cohort studies demonstrate that symptoms of GERD occur monthly in almost 50% of US adults and weekly in almost 20%. Three large case-control studies demonstrate a positive association between reflux symptoms and risk of adenocarcinoma of the esophagus, with more prolonged and severe symptoms accentuating this risk. However, because of the low incidence of adenocarcinoma of the esophagus and the ubiquity of reflux symptoms, the risk of cancer in any given individual with reflux symptoms is low. No randomized trial data are available to demonstrate either decreased cancer incidence or increased life expectancy in subjects with GERD who undergo screening endoscopy.
Strong evidence supports the association of GERD and adenocarcinoma of the esophagus; however, the risk of cancer in any given individual with GERD is low. Barrett esophagus appears to be a common precursor lesion to this cancer. Given the low absolute risk of cancer in those with GERD and the lack of demonstrated efficacy of endoscopic screening, insufficient evidence exists to endorse routine endoscopic screening of patients with chronic GERD symptoms.
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