Barrett Esophagus: Symptoms and Endoscopic Features
Barrett Esophagus: Symptoms and Endoscopic Features
Objectives: Risk stratification of Barrett's esophagus (BE) patients based on clinical and endoscopic features may help to optimize surveillance practice for esophageal adenocarcinoma (EAC) development. The aim of this study was to investigate patient symptoms and endoscopic features at index endoscopy and risk of neoplastic progression in a large population-based cohort of BE patients.
Methods: A retrospective review of hospital records relating to incident BE diagnosis was conducted in a subset of patients with specialized intestinal metaplasia from the Northern Ireland BE register. Patients were matched to the Northern Ireland Cancer Registry to identify progressors to EAC or esophageal high-grade dysplasia (HGD). Cox proportional hazards models were applied to evaluate the association between endoscopic features, symptoms, and neoplastic progression risk.
Results: During 27,997 person-years of follow-up, 128 of 3,148 BE patients progressed to develop HGD/EAC. Ulceration within the Barrett's segment, but not elsewhere in the esophagus, was associated with an increased risk of progression (hazard ratio (HR) 1.72; 95% confidence interval (CI): 1.08–2.76). Long-segment BE carried a significant sevenfold increased risk of progression compared with short-segment BE; none of the latter group developed EAC during the study period. Conversely, the absence of reflux symptoms was associated with an increased risk of cancer progression (HR 1.61; 95% CI: 1.05–2.46).
Conclusions: BE patients presenting with a long-segment BE or Barrett's ulcer have an increased risk of progressing to HGD/EAC and should be considered for more intense surveillance. The absence of reflux symptoms at BE diagnosis is not associated with a reduced risk of malignant progression, and may carry an increased risk of progression.
Barrett's esophagus (BE), metaplasia of the normal esophageal squamous epithelium into specialized columnar epithelium, is rising in incidence (over and above endoscopy rates) throughout the Western world. The importance of BE lies in the fact that it is a precursor of esophageal adenocarcinoma (EAC), a tumor that has a poor prognosis. The opportunity for detection of BE, and potential prevention of adenocarcinoma, has led gastroenterology organizations worldwide to endorse endoscopic surveillance of BE patients. However, endoscopic surveillance of BE is controversial because of ongoing debate as to its cost effectiveness. Identifying patients at greatest risk of neoplastic progression, which only occurs in a minority of cases, is a key priority in order to optimize the usefulness of such surveillance programs.
BE and EAC are both thought to result from repeated exposure to bile and gastric acid in the distal esophagus. A landmark publication from a Swedish population-based case–control study demonstrated that individuals reporting weekly reflux symptoms were at a sevenfold increased risk of EAC. Moreover, a dose–response relationship with frequency of symptoms was also noted. However, in contrast to the link between symptoms in the general population and development of EAC, the relationship between reflux symptoms experienced at presentation of BE and subsequent risk of neoplastic progression is less certain.
BE is thought to represent an adaptive response to acid-induced injury and ulceration, and therefore it is not unexpected that a substantial proportion of BE patients purport to be asymptomatic. The relevance of reflux, and other, symptoms present BE at diagnosis for stratification of cancer risk and associated need for surveillance is yet to be determined. Stratification of patients for surveillance based on other endoscopic findings at BE presentation, such as esophagitis and ulceration, has also been suggested by some studies. However, previous studies seeking to explore the association between these findings and EAC risk in a sequential manner have been limited by relatively small numbers of outcomes or lack of adjustment for known confounders, such as the presence of low-grade dysplasia.
The aim of this study was to examine the association between symptoms and endoscopic features in incident BE patients and their risk of neoplastic progression in a large population-based cohort.
Abstract and Introduction
Abstract
Objectives: Risk stratification of Barrett's esophagus (BE) patients based on clinical and endoscopic features may help to optimize surveillance practice for esophageal adenocarcinoma (EAC) development. The aim of this study was to investigate patient symptoms and endoscopic features at index endoscopy and risk of neoplastic progression in a large population-based cohort of BE patients.
Methods: A retrospective review of hospital records relating to incident BE diagnosis was conducted in a subset of patients with specialized intestinal metaplasia from the Northern Ireland BE register. Patients were matched to the Northern Ireland Cancer Registry to identify progressors to EAC or esophageal high-grade dysplasia (HGD). Cox proportional hazards models were applied to evaluate the association between endoscopic features, symptoms, and neoplastic progression risk.
Results: During 27,997 person-years of follow-up, 128 of 3,148 BE patients progressed to develop HGD/EAC. Ulceration within the Barrett's segment, but not elsewhere in the esophagus, was associated with an increased risk of progression (hazard ratio (HR) 1.72; 95% confidence interval (CI): 1.08–2.76). Long-segment BE carried a significant sevenfold increased risk of progression compared with short-segment BE; none of the latter group developed EAC during the study period. Conversely, the absence of reflux symptoms was associated with an increased risk of cancer progression (HR 1.61; 95% CI: 1.05–2.46).
Conclusions: BE patients presenting with a long-segment BE or Barrett's ulcer have an increased risk of progressing to HGD/EAC and should be considered for more intense surveillance. The absence of reflux symptoms at BE diagnosis is not associated with a reduced risk of malignant progression, and may carry an increased risk of progression.
Introduction
Barrett's esophagus (BE), metaplasia of the normal esophageal squamous epithelium into specialized columnar epithelium, is rising in incidence (over and above endoscopy rates) throughout the Western world. The importance of BE lies in the fact that it is a precursor of esophageal adenocarcinoma (EAC), a tumor that has a poor prognosis. The opportunity for detection of BE, and potential prevention of adenocarcinoma, has led gastroenterology organizations worldwide to endorse endoscopic surveillance of BE patients. However, endoscopic surveillance of BE is controversial because of ongoing debate as to its cost effectiveness. Identifying patients at greatest risk of neoplastic progression, which only occurs in a minority of cases, is a key priority in order to optimize the usefulness of such surveillance programs.
BE and EAC are both thought to result from repeated exposure to bile and gastric acid in the distal esophagus. A landmark publication from a Swedish population-based case–control study demonstrated that individuals reporting weekly reflux symptoms were at a sevenfold increased risk of EAC. Moreover, a dose–response relationship with frequency of symptoms was also noted. However, in contrast to the link between symptoms in the general population and development of EAC, the relationship between reflux symptoms experienced at presentation of BE and subsequent risk of neoplastic progression is less certain.
BE is thought to represent an adaptive response to acid-induced injury and ulceration, and therefore it is not unexpected that a substantial proportion of BE patients purport to be asymptomatic. The relevance of reflux, and other, symptoms present BE at diagnosis for stratification of cancer risk and associated need for surveillance is yet to be determined. Stratification of patients for surveillance based on other endoscopic findings at BE presentation, such as esophagitis and ulceration, has also been suggested by some studies. However, previous studies seeking to explore the association between these findings and EAC risk in a sequential manner have been limited by relatively small numbers of outcomes or lack of adjustment for known confounders, such as the presence of low-grade dysplasia.
The aim of this study was to examine the association between symptoms and endoscopic features in incident BE patients and their risk of neoplastic progression in a large population-based cohort.
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