/pdf/pathology-and-genetics-of-tumours-of-the-digestive-system-3xy9cwrc3c.pdf

Pathology and genetics of tumours of the digestive system

Pathology and genetics: Tumours of the digestive system

Background & Aims: The diagnosis and management of Barrett's esophagus (BE) are controversial. We conducted a critical review of the literature in BE to provide guidance on clinically relevant issues. Methods: A multidisciplinary group of 18 participants evaluated the strength and the grade of evidence for 42 statements pertaining to the diagnosis, screening, surveillance, and treatment of BE. Each member anonymously voted to accept or reject statements based on the strength of evidence and his own expert opinion. Results: There was strong consensus on most statements for acceptance or rejection. Members rejected statements that screening for BE has been shown to improve mortality from adenocarcinoma or to be cost-effective. Contrary to published clinical guidelines, they did not feel that screening should be recommended for adults over age 50, regardless of age or duration of heartburn. Members were divided on whether surveillance prolongs survival, although the majority agreed that it detects curable neoplasia and can be cost-effective in selected patients. The majority did not feel that acid-reduction therapy reduces the risk of esophageal adenocarcinoma but did agree that nonsteroidal antiinflammatory drugs are associated with a cancer risk reduction and are of promising (but unproven) value. Participants rejected the notion that mucosal ablation with acid suppression prevents adenocarcinoma in BE but agreed that this may be an appropriate strategy in a subgroup of patients with high-grade dysplasia. Conclusions: Based on this review of BE, the opinions of workshop members on issues pertaining to screening and surveillance are at variance with published clinical guidelines.

https://www.ualberta.ca/~loewen/Medicine/GIM%20Residents%20Core%20Reading/DYSPHAGIA,%20GERD,%20BARRETTS%20ESOPHAGUS/barrettscriticalreviewGastro.pdf

A critical review of the diagnosis and management of Barrett’s esophagus: the AGA Chicago Workshop

Clinical esophageal pH recording: A technical review for practice guideline development

https://www.gastrojournal.org/article/0016-5085(94)90123-6/pdf

Duodenogastroesophageal reflux: relationship to pH and importance in Barrett's esophagus

The factors contributing to the development of esophageal mucosal injury in gastroesophageal reflux disease (GERD) are unclear. The lower esophageal sphincter, esophageal acid and acid/alkaline exposure, and the presence of excessive duodenogastric reflux (DGR) was evaluated in 205 consecutive patients with GERD and various degrees of mucosal injury (no mucosal injury, n = 92; esophagitis, n = 66; stricture, n = 19; Barrett's esophagus, n = 28). Manometry and 24-hour esophageal pH monitoring showed that the prevalence and severity of esophageal mucosal injury was higher in patients with a mechanically defective lower esophageal sphincter (p less than 0.01) or increased esophageal acid/alkaline exposure (p less than 0.01) as compared with those with a normal sphincter or only increased esophageal acid exposure. Complications of GERD were particularly frequent and severe in patients who had a combination of a defective sphincter and increased esophageal acid/alkaline exposure (p less than 0.01). Combined esophageal and gastric pH monitoring showed that esophageal alkaline exposure was increased only in GERD patients with DGR (p less than 0.05) and that DGR was more frequent in GERD patients with a stricture or Barrett's esophagus. A mechanically defective lower esophageal sphincter and reflux of acid gastric juice contaminated with duodenal contents therefore appear to be the most important determinants for the development of mucosal injury in GERD. This explains why some patients fail medical therapy and supports the surgical reconstruction of the defective sphincter as the most effective therapy.

Complications of gastroesophageal reflux disease. Role of the lower esophageal sphincter, esophageal acid and acid/alkaline exposure, and duodenogastric reflux.

Alkaline gastroesophageal reflux: implications in the development of complications in Barrett's columnar-lined lower esophagus.

Duodenogastric reflux is a naturally occurring sporadic event, the incidence, occurrence, and detrimental effects of which have been difficult to assess The reliability of 24-hour gastric pH monitoring to detect duodenogastric reflux was studied Central to the use of pH monitoring for this purpose is confidence in its ability to measure and display pH data in a way that reflects changes in the gastric pH environment with sufficient sensitivity To test this the gastric pH of 10 dogs was measured in the fasting state, after feeding, and after pentagastrin stimulation The antrum was more alkaline in the fasting state (p less than 001) and the display of data by frequency distribution graph was sensitive enough to reflect induced pH changes To test the consistency of gastric pH at a given position, simultaneous 24-hour gastric monitoring was performed in 12 normal subjects with two probes placed at either 5 or 10 cm below the lower esophageal sphincter Only at the 5-cm position did the two probes read within 1 pH unit of each other more than 90% of the time Based on these principles, gastric pH monitoring was performed 5 cm below the lower esophageal sphincter in 30 normal subjects and 11 patients, fulfilling Ritchie's clinical criteria for pathologic duodenogastric reflux The data obtained was arranged into 71 variables and subjected to discriminant analysis Sixteen variables were identified, each with a corresponding coefficient to be used as a multiplier to derive a score A score of more than +22 indicated a high probability of pathologic duodenogastric reflux The test was applied to a validation population consisting of 10 additional normal subjects and 10 patients meeting Ritchie's criteria All normal subjects had a normal score and all but one (90%) of the patients had an abnormal score When compared to O-diisopropyl iminodiacetic acid (DISIDA) scintigraphy in another group of 22 normal subjects and 60 patients, 24-hour gastric pH monitoring was superior in the detection of pathologic duodenogastric reflux The study shows how the application of computer technology can be used to diagnose pathologic duodenogastric reflux in patients with complex foregut complaints

Computerized identification of pathologic duodenogastric reflux using 24-hour gastric pH monitoring.

Ambulatory 24-hour esophageal manometry was applied to analyze motility in 12 normal subjects and 9 patients with chest pain and dysphagia caused by diffuse esophageal spasm (DES). Pain episodes characterized by nonperistaltic activity occurred in 7 of 9 patients. A score based on 10 variables of the motility pattern differentiated patients from normal subjects and quantitated the severity of the disorder. Ambulatory motility monitoring was prospectively performed in 8 normal subjects and 37 patients: 8 with DES, 13 with hypertensive contractions, and 16 with a nonspecific disorder on standard manometry. The score was positive in 6 of 8 patients with DES and negative in all normal subjects (accuracy 87 percent). Nine of the 13 patients with hypertensive contractions (70 percent) and 6 of 16 with nonspecific disorders (38 percent) had a pathologic score reflecting a dysmotility as severe as DES. Ambulatory esophageal manometry is a more physiologic way to identify a motor disorder than standard manometry and has the potential to improve selection of patients for a surgical myotomy.

Antony P. Barlow

Papers

Complications of gastroesophageal reflux disease. Role of the lower esophageal sphincter, esophageal acid and acid/alkaline exposure, and duodenogastric reflux.

Alkaline gastroesophageal reflux: implications in the development of complications in Barrett's columnar-lined lower esophagus.

Computerized identification of pathologic duodenogastric reflux using 24-hour gastric pH monitoring.

A new technique to define and clarify esophageal motor disorders

Surgery and current management for cancer of the esophagus and cardia: Part II.