Of the 353 patients who presented for gastroscopy during the study period, the predominant symptoms, as expected, were heartburn and acid regurgitation, but patients also presented with nocturnal symptoms (11.3%), dysphagia (9.4%), hoarseness (5.5%) or atypical chest pain (4.2%). Endoscopically diagnosed esophagitis, identified in 26% of patients, may be under-represented considering 56% of patients were already taking a PPI at the time of endoscopy. ESEM was present in 12% of patients who underwent endoscopies. In addition, EE was suspected at endoscopy in three cases, but a biopsy was taken in only one of these patients. An independent, blinded histological review of all biopsy material in 65 patients yielded 10 cases of Barrett’s esophagus, using a traditional definition. Adopting the Montreal definition of Barrett’s esophagus proposed by Vakil et al (1
), the number of Barrett’s cases increased to 49. In addition, five cases of EE were diagnosed histologically.
The strengths of the present study include the broad generalizability of the study population referred for an initial gastroscopy for GERD-like symptoms to a general gastroenterology practice, and the independent reviews of endoscopic images and histology slides. While the present study is useful in answering the clinical aims we set out to address, there are important limitations. First, as a retrospective study, the clinical information for all of the categories studied was not readily available for every patient and depended on what was recorded as part of routine practice. This limitation is especially true for the presence of specific symptoms that may be influenced by detection or recall biases. Second, while the endoscopic images were prospectively reviewed, pictures were absent in a minority of cases. Finally, only 65 patients had esophageal biopsies.
Dysphagia emerged as a frequent presenting symptom of GERD in the present study. Of the 29 patients who complained of dysphagia, this symptom was explained by endoscopic findings in five cases, including four with Schatzki rings and one with a stricture. In addition, 11 of the 29 patients (37.9%) with dysphagia had reflux esophagitis, a figure comparable with previously reported data (11
The new definition proposed by Vakil et al (1
) is controversial, and clearly has the potential to dramatically affect the number of patients diagnosed with Barrett’s esophagus. Whereas only 10 of 353 patients (2.8%) referred for evaluation met the classic diagnostic criteria for Barrett’s esophagus, using the Montreal consensus definition would increase that number to 49 (14%), a fivefold increase. Among patients biopsied, 15% were diagnosed with Barrett’s esophagus using traditional criteria, in contrast to 75% of patients if the new criteria were applied. We cannot be certain about the ‘true’ incidence because not all patients were biopsied; however, biopsies were collected in 34 of 41 patients exhibiting ESEM. In these patients, the proportion of Barrett’s diagnoses would rise from 24% to 97% with adoption of the Montreal histological definition. Whether this represents a definition that has greater sensitivity for detecting patients at increased risk of esophageal adenocarcinoma is unclear. Previous research has indicated that esophageal columnar metaplasia with specialized IM is most strongly associated with adenocarcinoma (12
). In contrast, the association between esophageal columnar metaplasia (cardiac or oxyntocardiac mucosa) without IM and adenocarcinoma has been more controversial (13
). The inadequacy of biopsy protocols currently being practiced worldwide results in a poor sensitivity at detecting IM within an ESEM (1
), which is one of the reasons for the proposed change in definition. Additionally, although the risk for adenocarcinoma is indeed highest with columnar metaplasia associated with IM, other forms of columnar metaplasia may also carry an associated risk (16
). In fact, studies on patients with IM have shown that up to 35% of biopsies fail to demonstrate IM (12
), and that at least eight biopsies may be needed for a reasonable diagnostic yield (12
). The clinical impact of increased Barrett’s diagnostic rates is significant because both long-term daily PPI therapy and inclusion in an endoscopic surveillance program are currently recommended for patients with a diagnosis of Barrett’s esophagus (18
EE was observed in five patients (1.4% of all patients). Among patients biopsied, 7.7% of patients met the criteria for EE. These figures may represent underestimates because this diagnosis was not suspected endoscopically in four of the five patients. In addition, only one of the five patients was diagnosed with EE on histology before our audit. Three of the five cases of EE were convincing, with eosinophil counts of greater than 100/hpf, while the remaining two had borderline eosinophil counts of 21/hpf and 26/hpf, respectively. The histological underdiagnosis may be partly explained by reports suggesting that variable numbers of eosinophils may also be noted in GERD (21
). Currently, it is unclear whether the plethora of recent adult EE reports are related to an increase in diagnosis or an increase in the incidence of this condition (2
). Presently, the most useful predictors appear to be clinical and not endoscopic, including male sex and a history of atopy (2
). Despite the small sample size, our results show that instances of EE may have no distinguishing clinical or endoscopic features, suggesting that perhaps routine biopsies should be considered in all patients presenting with esophageal complaints (2
). In addition, there appears to be a need for a heightened awareness of EE among clinicians, endoscopists and pathologists. A better correlation between the clinical and/or endoscopic suspicions and pathological findings through closer communication between clinicians and pathologists may help improve detection rates. This is especially relevant because specifically targeted therapy for EE may be required for timely and complete symptom resolution.
With all of the above information, we attempted to quantify, in an exploratory fashion, the possible impact of these issues on clinical management, by extrapolating from the documented formal management recommendations recorded in the chart based on the initial consult and endoscopy report. Patients who had had a change in medication or its dose, those diagnosed with EE or those patients who were subsequently diagnosed with Barrett’s esophagus, and thus needing subsequent surveillance (irrelevant of any change in medication that may have also occurred), were considered as having undergone a change in management compared with the pre-assessment status. This classification was independently reviewed by an experienced clinician with particular expertise in esophageal diseases (A Barkun). The clinical management of GERD patients was altered in 95 patients (27%; 95% CI 22% to 32%). Eighty-four of the 95 patients had a change of medications, including starting a PPI in 65 patients or increasing the PPI dose in 19 patients. Ten of the 95 patients were diagnosed with Barrett’s esophagus and entered into an endoscopic surveillance program. One was diagnosed as having EE. Using the Montreal consensus definition of Barrett’s esophagus, above and beyond these 95 patients, an additional 39 patients with columnar metaplasia but without IM would be considered for surveillance. Finally, an additional four patients were diagnosed with EE after the independent review was initiated as part of the present audit. The breakdown of patients is shown in ; up to 43 additional patients (12%; 95% CI 8.6% to 16%) would have undergone a change from current management.
Exploratory analysis of the potential impact on routine management of patients with gastroesophageal reflux disease (GERD)-like symptoms undergoing a gastroscopy
The newly proposed Montreal consensus definition of Barrett’s esophagus is controversial and, if implemented, would greatly increase the number of patients diagnosed with this condition. In addition, EE is a diagnosis that is probably much more prevalent than currently recognized, and may be missed in patients presenting with GERD-like symptoms. Both of these issues thus have the potential to significantly alter clinical practice. Prospective studies need to be undertaken to better define the implications of these findings.