摘要
Background: The incidence of distal oesophageal adenocarcinoma is rising, with chronic reflux and Barretts oesophagus being considered risk factors. Reliable detection of Barretts oesophagus during upper endoscopy is therefore mandatory but requires both endoscopy and histology for confirmation. Appropriate management of patients with endoscopic suspicion but negative on histology, or vice versa, or of patients with no endoscopic suspicion but with a biopsy diagnosis of intestinal metaplasia at the gastro oesophageal junction, has not yet been studied prospectively. Patients and methods: In a prospective multicentre study, 929 patients (51%male, mean age 50 years) referred for upper gastrointestinal endoscopy were included; 59%had reflux symptoms. The endoscopic aspect of the Z line and any suspicion of Barretts oesophagus were noted, and biopsies were taken in all patients from the Z line (n = 4), gastric cardia (n = 2), and body and antrum (n = 2 each). Biopsies positive for specialised intestinal metaplasia (SIM) were reviewed by a reference pathologist for a final Barretts oesophagus diagnosis. All patients with endoscopic and/or histological suspicion of Barretts oesophagus were invited for a follow up endoscopy; the remaining cases (no endoscopic or histological suspicion of Barretts oesophagus) were followed clinically. Results: Of 235 patients positive for Barretts oesophagus on endoscopy and/or histology, 63%agreed to undergo repeat endoscopy (mean follow up period 30.5months). 46%of patients with an endoscopic Barretts oesophagus diagnosis but no histological confirmation (group A) showed the same distribution, a further 42%did not have Barretts oesophagus, and 11%had confirmed Barretts oesophagus on both endoscopy and biopsy on follow up. In the group with a histological Barretts oesophagus diagnosis but negative on initial endoscopy (group B), follow up showed the same in 26%whereas 46%had no Barretts oesophagus, and confirmed Barretts oesophagus (endoscopy plus histology) was diagnosed in 17%. Of the study population, 16 patients had Barretts oesophagus on initial endoscopy confirmed by histology which remained constant in 70%at follow up (group C). Of the remaining patients without an initial Barretts oesophagus diagnosis on either endoscopy or histology (groupD) and only clinical followup (mean follow up period 38 months), one confirmed Barretts oesophagus 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. Conclusions: Even in a specialised gastroenterology setting, reproducibility of presumptive endoscopic or histological diagnoses of Barretts oesophagus at follow up were poor. Only 10-20%of cases with either endoscopic or histological suspicion of Barretts oesophagus had established Barretts oesophagus after 2.5 years of follow up. The risk of dysplasia in this population was very low and hence meticulous follow up may not be required.
Background: The incidence of distal oesophageal adenocarcinoma is rising, with chronic reflux and Barretts oesophagus being considered risk factors. Reliable detection of Barretts oesophagus during upper endoscopy is therefore mandatory but requires both endoscopy and histology for confirmation. Appropriate management of patients with endoscopic suspicion but negative on histology, or vice versa, or of patients with no endoscopic suspicion but with a biopsy diagnosis of intestinal metaplasia at the gastro oesophageal junction, has not yet been studied prospectively. Patients and methods: In a prospective multicentre study, 929 patients (51%male, mean age 50 years) referred for upper gastrointestinal endoscopy were included; 59%had reflux symptoms. The endoscopic aspect of the Z line and any suspicion of Barretts oesophagus were noted, and biopsies were taken in all patients from the Z line (n = 4), gastric cardia (n = 2), and body and antrum (n = 2 each). Biopsies positive for specialised intestinal metaplasia (SIM) were reviewed by a reference pathologist for a final Barretts oesophagus diagnosis. All patients with endoscopic and/or histological suspicion of Barretts oesophagus were invited for a follow up endoscopy; the remaining cases (no endoscopic or histological suspicion of Barretts oesophagus) were followed clinically. Results: Of 235 patients positive for Barretts oesophagus on endoscopy and/or histology, 63%agreed to undergo repeat endoscopy (mean follow up period 30.5months). 46%of patients with an endoscopic Barretts oesophagus diagnosis but no histological confirmation (group A) showed the same distribution, a further 42%did not have Barretts oesophagus, and 11%had confirmed Barretts oesophagus on both endoscopy and biopsy on follow up. In the group with a histological Barretts oesophagus diagnosis but negative on initial endoscopy (group B), follow up showed the same in 26%whereas 46%had no Barretts oesophagus, and confirmed Barretts oesophagus (endoscopy plus histology) was diagnosed in 17%. Of the study population, 16 patients had Barretts oesophagus on initial endoscopy confirmed by histology which remained constant in 70%at follow up (group C). Of the remaining patients without an initial Barretts oesophagus diagnosis on either endoscopy or histology (groupD) and only clinical followup (mean follow up period 38 months), one confirmed Barretts oesophagus 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. Conclusions: Even in a specialised gastroenterology setting, reproducibility of presumptive endoscopic or histological diagnoses of Barretts oesophagus at follow up were poor. Only 10-20%of cases with either endoscopic or histological suspicion of Barretts oesophagus had established Barretts oesophagus after 2.5 years of follow up. The risk of dysplasia in this population was very low and hence meticulous follow up may not be required.