Diagnosis of Barrett's esophagus

To date, timely diagnosis of Barrett's esophagus presents significant difficulties.

In a number of cases, in the examination of patients with Barrett's esophagus, esophagus manometry is performed, which allows to detect a decrease in pressure in the region of the lower sphincter of the esophagus. The possibilities of endoscopic ultrasound scanning of the esophagus in the diagnosis of Barrett's esophagus are not yet clear.

[1], [2], [3], [4], [5], [6]

Endoscopic diagnosis of Barrett's esophagus

Among objective methods of diagnosing Barrett's esophagus, esophagoscopy with targeted esophagobiopsy of the mucous membrane is currently important. According to endoscopic studies, the coloration of the mucosa of the esophagus depends largely on the intensity of its illumination, however, the unmodified mucosa of the esophagus is more often pale with a slight pink tinge; folds of medium size, well spread out when filling the esophagus with air.

As our observations showed, the most likely finding of Barrett's esophagus according to visual examination through the endofibroscope in the following cases:

• if there is more or less reddish or bright pink in the color of the mucosa of the terminal section of the esophagus, of various lengths, in the proximal direction 2-4 cm from the cardia socket in the form of a continuous, more or less circularly located portion of the mucosa or in the form of reddish "tongues" "Of different lengths, analogous to color, localized proximal to the cardia socket and further in the proximal direction, gradually decreasing in transverse dimensions, between which is more proximal in color e palely lustrous surface with unmodified mucosa of the esophagus;
• in the presence of an ulcer of the esophagus, surrounded by a corolla of a reddish or pink mucous membrane, the width of which may be different on a pale background with a glossy surface of the mucosa of the esophagus;
• when the condition changes, the epithelium becomes more pinkish-red (later red), "velvety" and loose mucosa appear.

In such cases, the boundary between the various mucosal structures is easily distinguishable (especially in the absence of pronounced inflammatory changes). A combination of the above features is possible.

It is customary to distinguish between long and short segments of the "languages" of the metaplastic epithelium of the terminal section of the esophagus, respectively, in the proximal direction from the cardiac socket more than 3 cm or less. In patients with long red "tongues" of the mucous membrane of the esophagus, hypersecretion of the stomach secreted by acid is revealed more often, according to the pH-metry, and in patients with short "lengthy" "tongues" - reduced or normal acid formation in the stomach.

In general, the above characteristics should be treated with some caution. We have repeatedly observed that, with successful treatment of patients, these "languages" in some patients disappeared quite quickly (often within 3-4 weeks), in similar cases and histological examination of biopsy material also there was no evidence in favor of Barrett's esophagus. Therefore, only a long observation of patients against the background of the treatment and the conduct of multiple targeted esophagobiopsy will allow to establish or exclude the presence of a condition such as Barrett's esophagus.

The boundary between the single-layered cylindrical epithelium of the stomach and the multilayered flat epithelium of the esophagus, the so-called Z-line, in some patients is somewhat "shifted" in the proximal direction. Therefore, the detection of less than 2 cm proximal to the Z-line in such patients in the terminal esophagus of the gastric epithelium is not yet an indicator of the presence of Barrett's esophagus. It is quite justified the opinion of some researchers on the expediency of circular conducting of multiple esophagobiopsy of the mucous membrane with a suspected Barrett esophagus (at least 4 fragments at a distance of about 2 cm from each other) by 2-4 cm proximal to the upper border of the folds of the stomach, which are usually clearly visible through the endofibroscope . Only the detection of goblet cells in the metaplastic cylindrical epithelium localized in the distal esophagus can serve as a convincing criterion for the presence of Barrett's esophagus.

The endoscopic picture of the esophagus mucosa in reflux-esophagitis in patients with GERD is very variable. To a large extent this is due to the condition of patients during endoscopy and the abilities of an endoscopist, which allows to describe the revealed changes in the mucosa of the esophagus, the presence of a variety of classifications of GERD, the individual stages of which are often significantly different from each other. The endoscopic picture of the state of the mucosa of the esophagus depends, according to our observations, on the intensity and prevalence of diffuse inflammatory changes, the presence of erosions, ulcers and / or esophageal stricture, their severity (including the same patient in the period of improvement and / or deterioration of it condition), as well as from illumination of the mucous membrane during the endoscopic examination of patients. In some cases, endoscopic signs of esophagitis may be edema of the mucosa of the esophagus with foci of hyperemia (including red spots of various sizes and lengths), with more severe esophagitis - against the background of a surface whitish plaque (necrosis), non-uniform longitudinally directed hyperemic bands; with moderately expressed esophagitis, uneven white streaks (streaks) can be seen, among which there are clearly more significant lesions of the mucosa of the esophagus; with severe esophagitis - grayish white, necrosis of the mucosa with a narrowing of the lumen of the esophagus or without it. In more severe cases, the mucous membrane of the esophagus can be covered with a "spotted" species of necrotic easily removed pseudomembrane, under which a bleeding surface is exposed. Such changes in the mucosa of the esophagus are very similar to the pathological changes that occur with ulcerative colitis.

The extent of metaplasia in the Barrett's esophagus is directly proportional to the time during which the pH value in the esophagus is less than 4. It is not clear, however, whether the previous acid-inhibiting therapy affects the extent of the previously diagnosed Barrett's esophagus.

Based on the results of studying the computer database of the Department of War Veterans and prospectively selected for the study of patients with Barrett's esophagus, previously treated with acid-inhibiting drugs before the detection of Barrett's esophagus, and patients who did not receive such therapy, according to the endoscopic comparison of the Barrett's esophagus, it was established that its average length During the initial diagnosis, 4.4 cm. Among these patients, 139 (41%) had previously been treated with H2 receptor antagonists or proton n (41 patients were treated with both drugs), and 201 patients (59%) before identifying Barrett's esophagus did not take any of these drugs. The average length of Barrett's esophagus was significantly lower in patients who had previously been treated with proton pump inhibitors (3.4 cm) or proton pump inhibitors in combination with histamine H2 receptor antagonists (3.1 cm) compared with those who did not receive none of the above options for drug therapy (4.8 cm). Based on the study, the authors believe that the use of acid-inhibiting therapy is associated with the previous possible length of the recently diagnosed Barrett's esophagus in GERD. This fact does not depend on the year of diagnosis (1981-2000) or the demographic indicators of patients (age, sex, ethnos, the presence of intestinal metaplasia). However, in order to confirm the findings, the authors of this report consider it necessary to conduct further research.

When esophagoscopy, there are certain difficulties in carrying out targeted esophagobiopsy (increased esophagus peristalsis, expressed gastroesophageal reflux, small spoons of biopsy forceps, which allow obtaining only a small amount of material for histological examination, restless behavior of the patient).

[7], [8], [9], [10]

Differential diagnosis of Barrett's esophagus

When carrying out differential diagnosis of the unmodified mucosa of the esophagus with the mucous membrane, considered as characteristic of the Barrett's esophagus, it must be taken into account that, in normal cases, the gastric mucosa in some patients is shifted somewhat to the distal esophagus, so the detection of epithelium similar in color to such patients gastric epithelium, is not yet an indicator indicating the presence of Barrett's esophagus (in such cases it is advisable to carry out multiple scans to clarify the diagnosis biopsies followed by histological examination of the resulting mucosal fragments).

The often observed unevenness ("patchiness") of the location on the esophageal mucosa of the sites of metaplasia and dysplasia is noticed, as a result of this in a number of cases a biopsy of these areas is carried out. With small fragments of the mucous membrane obtained during a biopsy, it is often difficult to interpret them.

When evaluating the biopsy material, observations have shown that it is necessary to differentiate the neoplastic transformation from the reactive and regenerative changes in the mucosa. It is suggested in doubtful cases to distinguish such dysplasia as "vague", in contrast to high and low dysplasia and, of course, to take such patients for dynamic observation.

[11], [12], [13]