Difference between revisions of "Barrett's esophagus"

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{{ Infobox diagnosis
{{ Infobox diagnosis
| Name      = {{PAGENAME}}
| Name      = {{PAGENAME}}
| Image      = Barretts_alcian_blue.jpg  
| Image      = Esophagus with intestinal metaplasia -- intermed mag.jpg
| Width      =
| Width      =
| Caption    = Barrett esophagus. [[Alcian blue stain]].  
| Caption    = Esophagus with intestinal metaplasia, as seen in Barrett esophagus. [[H&E stain]].  
| Micro      = columnar epithelium with goblet cells
| Micro      = columnar epithelium with goblet cells
| Subtypes  =
| Subtypes  =
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| Other      =
| Other      =
| ClinDDx    =
| ClinDDx    =
| Tx        = on-going surveillance for [[columnar dysplasia of the esophagus|columnar dysplasia]]
}}
}}
:''Intestinal metaplasia of the esophagus'' redirects here.
:''Intestinal metaplasia of the esophagus'' redirects here.
'''Barrett esophagus''', abbreviated '''BE''', is a relatively common pathology of the esophagus that is associated with an increased risk of [[esophageal adenocarcinoma]].
'''Barrett's esophagus''', abbreviated '''BE''', is a relatively common pathology of the [[esophagus]], that is associated with an increased risk of [[esophageal adenocarcinoma]].


==General==
==General==
*Diagnosis is made by '''clinicans ''not'' pathologists'''.
*Diagnosis is made by '''clinicans ''not'' pathologists'''.
**A common histologic correlate is metaplastic transformation of stratified squamous epithelium to simple columnar epithelium with goblet cells.
**A common histologic correlate is metaplastic transformation of stratified squamous epithelium to simple columnar epithelium with goblet cells.
***There is disagreement whether goblet cells are required for the diagnosis.<ref name=pmid19623166>{{Cite journal  | last1 = Riddell | first1 = RH. | last2 = Odze | first2 = RD. | title = Definition of Barrett's esophagus: time for a rethink--is intestinal metaplasia dead? | journal = Am J Gastroenterol | volume = 104 | issue = 10 | pages = 2588-94 | month = Oct | year = 2009 | doi = 10.1038/ajg.2009.390 | PMID = 19623166 }}</ref>
***There is disagreement whether goblet cells are required for the diagnosis.<ref name=pmid19623166>{{Cite journal  | last1 = Riddell | first1 = RH. | last2 = Odze | first2 = RD. | title = Definition of Barrett's esophagus: time for a rethink--is intestinal metaplasia dead? | journal = Am J Gastroenterol | volume = 104 | issue = 10 | pages = 2588-94 | month = Oct | year = 2009 | doi = 10.1038/ajg.2009.390 | PMID = 19623166 }}</ref> In the United States and Canada goblet cells are required for the diagnosis.<ref name=pmid29998421>{{cite journal |authors=Odze R |title=Histology of Barrett's Metaplasia: Do Goblet Cells Matter? |journal=Dig. Dis. Sci. |volume=63 |issue=8 |pages=2042–2051 |date=August 2018 |pmid=29998421 |doi=10.1007/s10620-018-5151-z |url=}}</ref> In the UK, goblet cells are not required.
****One large study suggests that goblets cells are only absent due to undersampling.<ref name=pmid21959311>{{Cite journal  | last1 = Chandrasoma | first1 = P. | last2 = Wijetunge | first2 = S. | last3 = DeMeester | first3 = S. | last4 = Ma | first4 = Y. | last5 = Hagen | first5 = J. | last6 = Zamis | first6 = L. | last7 = DeMeester | first7 = T. | title = Columnar-lined esophagus without intestinal metaplasia has no proven risk of adenocarcinoma. | journal = Am J Surg Pathol | volume = 36 | issue = 1 | pages = 1-7 | month = Jan | year = 2012 | doi = 10.1097/PAS.0b013e31822a5a2c | PMID = 21959311 }}</ref>
****One large study suggests that goblets cells are only absent due to undersampling.<ref name=pmid21959311>{{Cite journal  | last1 = Chandrasoma | first1 = P. | last2 = Wijetunge | first2 = S. | last3 = DeMeester | first3 = S. | last4 = Ma | first4 = Y. | last5 = Hagen | first5 = J. | last6 = Zamis | first6 = L. | last7 = DeMeester | first7 = T. | title = Columnar-lined esophagus without intestinal metaplasia has no proven risk of adenocarcinoma. | journal = Am J Surg Pathol | volume = 36 | issue = 1 | pages = 1-7 | month = Jan | year = 2012 | doi = 10.1097/PAS.0b013e31822a5a2c | PMID = 21959311 }}</ref>
*Associated with (chronic) [[gastroesophageal reflux disease]].
*Associated with [[gastroesophageal reflux disease]] (GERD).
**Considered to be a consequence of chronic GERD.<ref name=pmid21043812>{{Cite journal  | last1 = Yantiss | first1 = RK. | title = Diagnostic challenges in the pathologic evaluation of Barrett esophagus. | journal = Arch Pathol Lab Med | volume = 134 | issue = 11 | pages = 1589-600 | month = Nov | year = 2010 | doi = 10.1043/2009-0547-RAR1.1 | PMID = 21043812 }}</ref>


Significance of Barrett's esophagus:
Significance of Barrett's esophagus:
*Increased risk of adenocarcinoma of the esophagus.
*Increased risk of [[adenocarcinoma of the esophagus]].
**Need on-going surveillance, i.e. long term follow-up/repeat esophagogastroduodenoscopy.
**Need on-going surveillance, i.e. long term follow-up/repeat esophagogastroduodenoscopy.


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**Normal mucosa = light pink.
**Normal mucosa = light pink.


===Prague Classification Barrett's Esophagus===
*Commonly used in by endoscopists.
*Quantifies the extent of Barrett's esophagus.
Meaning:<ref name=pmid22248595>{{cite journal |vauthors=Vahabzadeh B, Seetharam AB, Cook MB, Wani S, Rastogi A, Bansal A, Early DS, Sharma P |title=Validation of the Prague C & M criteria for the endoscopic grading of Barrett's esophagus by gastroenterology trainees: a multicenter study |journal=Gastrointest Endosc |volume=75 |issue=2 |pages=236–41 |date=February 2012 |pmid=22248595 |pmc=4547779 |doi=10.1016/j.gie.2011.09.017 |url=}}</ref>
*C = circumferential length.
*M = maximal length.
===Images===
<gallery>
<gallery>
Image:Barretts_esophagus.jpg | Endoscopic image of BE. (WC)
Image:Barretts_esophagus.jpg | Endoscopic image of BE. (WC)
</gallery>
</gallery>
==Microscopic==
==Microscopic==
Features:
Features:
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*[[Helicobacter gastritis]].
*[[Helicobacter gastritis]].
*[[Low-grade columnar dysplasia of the esophagus]].
*[[Low-grade columnar dysplasia of the esophagus]].
*Carry over from a concurrent [[duodenum|duodenal]] biopsy - fragments with goblets cells have no gastric-type epithelium.


===Images===
===Images===
<gallery>
Image: Esophagus with intestinal metaplasia -- low mag.jpg | BE - low mag.
Image: Esophagus with intestinal metaplasia -- intermed mag.jpg | BE - intermed. mag.
Image: Esophagus with intestinal metaplasia -- high mag.jpg | BE - high mag.
</gallery>
<gallery>
<gallery>
Image:Barretts_alcian_blue.jpg | Barrett's type mucosa. [[Alcian blue stain]]. (WC)
Image:Barretts_alcian_blue.jpg | Barrett's type mucosa. [[Alcian blue stain]]. (WC)
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==Sign-out==
==Sign-out==
<pre>
Esophagus, Distal, Biopsy:
- Columnar epithelium with intestinal metaplasia, see comment.
- Reactive squamous epithelium.
- NEGATIVE for dysplasia and NEGATIVE for malignancy.
Comment:
The findings are consistent with Barrett's esophagus in the appropriate endoscopic setting.
</pre>
===Block letters===
<pre>
<pre>
ESOPHAGUS, DISTAL, BIOPSY:
ESOPHAGUS, DISTAL, BIOPSY:
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- COLUMNAR EPITHELIUM WITH INTESTINAL METAPLASIA AND MODERATE CHRONIC INFLAMMATION, SEE COMMENT.
- COLUMNAR EPITHELIUM WITH INTESTINAL METAPLASIA AND MODERATE CHRONIC INFLAMMATION, SEE COMMENT.
- REACTIVE SQUAMOUS EPITHELIUM.
- REACTIVE SQUAMOUS EPITHELIUM.
- NEGATIVE FOR DYSPLASIA AND MALIGNANCY.
- NEGATIVE FOR DYSPLASIA AND NEGATIVE FOR MALIGNANCY.


COMMENT:
COMMENT:
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- SEE COMMENT.
- SEE COMMENT.
- REACTIVE SQUAMOUS EPITHELIUM.
- REACTIVE SQUAMOUS EPITHELIUM.
- NEGATIVE FOR DYSPLASIA AND MALIGNANCY.
- NEGATIVE FOR DYSPLASIA AND NEGATIVE FOR MALIGNANCY.


COMMENT:
COMMENT:

Latest revision as of 14:23, 15 September 2022

Barrett's esophagus
Diagnosis in short

Esophagus with intestinal metaplasia, as seen in Barrett esophagus. H&E stain.
LM columnar epithelium with goblet cells
LM DDx low-grade columnar dysplasia of the esophagus, gastroesophageal reflux disease, nonspecific inflammation at the GE junction
Stains Alcian blue stain (pH 2.5)
Site esophagus
Associated Dx gastroesophageal reflux disease, esophageal adenocarcinoma, columnar dysplasia of the esophagus
Prevalence relatively common
Endoscopy red/light brown esophageal mucosa, at gastro-esophageal junction
Prognosis good
Treatment on-going surveillance for columnar dysplasia
Intestinal metaplasia of the esophagus redirects here.

Barrett's esophagus, abbreviated BE, is a relatively common pathology of the esophagus, that is associated with an increased risk of esophageal adenocarcinoma.

General

  • Diagnosis is made by clinicans not pathologists.
    • A common histologic correlate is metaplastic transformation of stratified squamous epithelium to simple columnar epithelium with goblet cells.
      • There is disagreement whether goblet cells are required for the diagnosis.[1] In the United States and Canada goblet cells are required for the diagnosis.[2] In the UK, goblet cells are not required.
        • One large study suggests that goblets cells are only absent due to undersampling.[3]
  • Associated with gastroesophageal reflux disease (GERD).
    • Considered to be a consequence of chronic GERD.[4]

Significance of Barrett's esophagus:

Gross

  • Red/light brown esophageal mucosa.
    • Normal mucosa = light pink.

Prague Classification Barrett's Esophagus

  • Commonly used in by endoscopists.
  • Quantifies the extent of Barrett's esophagus.

Meaning:[5]

  • C = circumferential length.
  • M = maximal length.

Images

  • Endoscopic image of BE. (WC)

Microscopic

Features:

  • Columnar epithelium with:
    • Goblet cells - key feature.
    • +/-Moderate chronic inflammation +/- acute inflammation -- common.[6]
    • +/-Mild nuclear hyperchromasia.
  • +/-Squamous epithelium with changes of gastroesophageal reflux.

DDx:

Images

  • BE - low mag.

  • BE - intermed. mag.

  • BE - high mag.

  • Barrett's type mucosa. Alcian blue stain. (WC)

  • Barrett's type mucosa. Alcian blue stain. (WC/AFIP)

  • Barrett's type mucosa. Alcian blue stain. (WC/AFIP)

Stains

  • Alcian blue (pH 2.5)[7] - goblet cells +ve.

Sign-out

Esophagus, Distal, Biopsy:
- Columnar epithelium with intestinal metaplasia, see comment.
- Reactive squamous epithelium.
- NEGATIVE for dysplasia and NEGATIVE for malignancy.

Comment:
The findings are consistent with Barrett's esophagus in the appropriate endoscopic setting.

Block letters

ESOPHAGUS, DISTAL, BIOPSY:
- COLUMNAR EPITHELIUM WITH INTESTINAL METAPLASIA AND MILD ACUTE INFLAMMATION, SEE COMMENT.
- REACTIVE SQUAMOUS EPITHELIUM.
- NEGATIVE FOR DYSPLASIA AND NEGATIVE FOR MALIGNANCY.

COMMENT:
The findings are consistent with Barrett's esophagus in the appropriate endoscopic setting.

ESOPHAGUS, DISTAL, BIOPSY:
- COLUMNAR EPITHELIUM WITH INTESTINAL METAPLASIA AND MODERATE CHRONIC INFLAMMATION, SEE COMMENT.
- REACTIVE SQUAMOUS EPITHELIUM.
- NEGATIVE FOR DYSPLASIA AND NEGATIVE FOR MALIGNANCY.

COMMENT:
The findings are consistent with Barrett's esophagus in the appropriate endoscopic setting.

ESOPHAGUS, DISTAL, BIOPSY:
- COLUMNAR EPITHELIUM WITH EXTENSIVE INTESTINAL METAPLASIA, ACUTE AND CHRONIC INFLAMMATION;
- SEE COMMENT.
- REACTIVE SQUAMOUS EPITHELIUM.
- NEGATIVE FOR DYSPLASIA AND NEGATIVE FOR MALIGNANCY.

COMMENT:
The columnar epithelium with intestinal metplasia is seen located deep to the squamous
epithelium.

The findings are consistent with Barrett's esophagus in the appropriate endoscopic setting.

See also

References

  1. ↑ Riddell, RH.; Odze, RD. (Oct 2009). "Definition of Barrett's esophagus: time for a rethink--is intestinal metaplasia dead?". Am J Gastroenterol 104 (10): 2588-94. doi:10.1038/ajg.2009.390. PMID 19623166.
  2. ↑ Odze R (August 2018). "Histology of Barrett's Metaplasia: Do Goblet Cells Matter?". Dig. Dis. Sci. 63 (8): 2042–2051. doi:10.1007/s10620-018-5151-z. PMID 29998421.
  3. ↑ Chandrasoma, P.; Wijetunge, S.; DeMeester, S.; Ma, Y.; Hagen, J.; Zamis, L.; DeMeester, T. (Jan 2012). "Columnar-lined esophagus without intestinal metaplasia has no proven risk of adenocarcinoma.". Am J Surg Pathol 36 (1): 1-7. doi:10.1097/PAS.0b013e31822a5a2c. PMID 21959311.
  4. ↑ Yantiss, RK. (Nov 2010). "Diagnostic challenges in the pathologic evaluation of Barrett esophagus.". Arch Pathol Lab Med 134 (11): 1589-600. doi:10.1043/2009-0547-RAR1.1. PMID 21043812.
  5. ↑ "Validation of the Prague C & M criteria for the endoscopic grading of Barrett's esophagus by gastroenterology trainees: a multicenter study". Gastrointest Endosc 75 (2): 236–41. February 2012. doi:10.1016/j.gie.2011.09.017. PMC 4547779. PMID 22248595. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4547779/.
  6. ↑ Voutilainen, M.; Färkkilä, M.; Mecklin, JP.; Juhola, M.; Sipponen, P. (Nov 1999). "Chronic inflammation at the gastroesophageal junction (carditis) appears to be a specific finding related to Helicobacter pylori infection and gastroesophageal reflux disease. The Central Finland Endoscopy Study Group.". Am J Gastroenterol 94 (11): 3175-80. doi:10.1111/j.1572-0241.1999.01513.x. PMID 10566710.
  7. ↑ Voutilainen, M.; Färkkilä, M.; Juhola, M.; Mecklin, JP.; Sipponen, P. (Nov 1999). "Complete and incomplete intestinal metaplasia at the oesophagogastric junction: prevalences and associations with endoscopic erosive oesophagitis and gastritis.". Gut 45 (5): 644-8. PMID 10517897.
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