Magnification Endoscopy with Acetic Acid for Barrett’s Esophagus

 

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Objectives

Barrett’s esophagus is present in approximately 6 %-12 % of patients undergoing endoscopy for symptomatic gastroesophageal reflux disease. It is currently defined as the presence of columnar epithelium of any length in the distal esophagus, if biopsies in these segments reveal specialized intestinal metaplasia with goblet cells when a combined hematoxylin and eosin/Alcian blue stain of pH 2.5 is applied. Segments less than 3 cm in length and greater than 3 cm are called short-segment and long-segment Barrett’s esophagus, respectively. Barrett’s esophagus is the only clearly recognized risk factor for adenocarcinoma of the esophagus and this risk is associated topographically with the areas of specialized intestinal metaplasia. Adenocarcinoma of the esophagus is detected with increasing frequency and its incidence continues to rise. The estimated annual cancer risk for a given patient with Barrett’s esophagus is approximately 0.5 %. The 5-year survival rate for this malignancy remains dismal, because survival is stage-dependent and currently most cancers are at advanced stages when detected. Strategies for an improved survival rate among patients with adenocarcinoma of the esophagus focus on improving the diagnosis of Barrett’s esophagus, on better identification of dysplasia, and on detection of cancer at earlier and potentially curable stages.

Current practice guidelines (the “Seattle protocol”) recommend endoscopy with four-quadrant biopsies, obtained with jumbo or standard biopsy forceps at 2- or 1-cm intervals in the involved segment of columnar-lined esophagus, for the diagnosis and surveillance of patients with Barrett’s esophagus. Intestinal metaplasia cannot be visualized with conventional endoscopes; this applies also to areas of intraepithelial neoplasia or superficial carcinoma in the absence of mucosal lesions such as nodules, polyps, or ulcers. Therefore multiple blind biopsy samples, according to the Seattle protocol, are recommended in the columnar metaplasia segment of the esophagus. In addition, however, intestinal metaplasia, intraepithelial neoplasia, and early carcinoma are distributed focally, quite often in small areas of less than 0.5cm² in the distal esophagus which will normally contain fundic and cardial types of mucosa. For this reason the Seattle protocol, in addition to being time-consuming and expensive, has a basic imprecision.

Chromoscopy is a helpful adjunct to endoscopic diagnosis in Barrett’s esophagus. Lugol’s solution (iodine-based absorptive dye) imparts a brown stain to glycogen-containing squamous epithelium but does not stain columnar epithelium including the epithelium in the columnar-lined esophagus. By improving the visualisation of the Z-line, Lugol staining slightly increases the accuracy of the endoscopic diagnosis of Barrett’s esophagus, but does not identify intestinal metaplasia. Methylene blue solution (0.5 %) is absorbed by well-differentiated enterocytes and has been proposed for the detection of areas with intestinal metaplasia in Barrett’s esophagus [1] [2]. Without doubt, the procedure has improved, the diagnosis and surveillance of patients with Barrett’s esophagus. However the selectivity of the reaction is influenced by the method used which requires a preliminary washing with a mucolytic agent and washing after dye projection. Because the intensity of the coloration is influenced by the cell differentiation, the reaction is weak in areas with intraepithelial neoplasia. Finally there is a potential risk of complications (vomiting and bronchial aspiration).

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J.-F. Rey, M.D.

Institute Arnault Tzanck

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