Barrett's esophagus (BE) is the only known precursor to esophageal adenocarcinoma (EAC), whose incidence has increased sharply in the last 4 decades. The annual conversion rate of BE to cancer is significant, but small. The identification of patients at a higher risk of cancer therefore poses a clinical conundrum. Currently, endoscopic surveillance is recommended in BE patients, with the aim of diagnosing either dysplasia or cancer at early stages, both of which are curable with minimally invasive endoscopic techniques. There is a large variation in clinical practice for endoscopic surveillance, and dysplasia as a marker of increased risk is affected by sampling error and high interobserver variability. Screening programs have not yet been formally accepted, mainly due to the economic burden that would be generated by upper gastrointestinal endoscopy. Screening programs have not yet been formally accepted, mainly due to the economic burden that would be generated by widespread indication to upper gastrointestinal endoscopy. In fact, it is currently difficult to formulate an accurate algorithm to confidently target the population at risk, based on the known clinical risk factors for BE and EAC. This review will focus on the clinical and molecular factors that are involved in the development of BE and its conversion to cancer and on how increased knowledge in these areas can improve the clinical management of the disease.
Adenocarcinoma/*etiology ; Animals ; Barrett Esophagus/*complications/diagnosis ; Diagnostic Imaging/methods ; Disease Models, Animal ; Epigenesis, Genetic/physiology ; Esophageal Neoplasms/diagnosis/*etiology ; Esophagoscopy/methods ; Forecasting ; Genetic Markers/physiology ; Humans ; Mice ; Practice Guidelines as Topic ; Risk Factors

Obesity is prevalent in Korea. An increase in food intake and a decrease in energy expenditure are responsible for obesity. Gut hormones play a role in controlling food intake. Obesity is suggested to be linked to common gastrointestinal functional disorders. Obesity is associated with an increased risk of gastroesophageal reflux disease, Barrett esophagus and esophageal adenocarcinoma. Epidemiologic studies indicate that obesity is associated with chronic gastrointestinal symptoms. This association suggests the possibility that obesity and functional gastrointestinal disorders may be pathophysiologically linked. However, data on the relationship between obesity and functional gastrointestinal disorders are inconsistent. In this paper, we review the role of gastrointestinal hormones in food intake and the relationship between obesity and functional gastrointestinal disorders.
Barrett Esophagus/*etiology ; Energy Intake ; Energy Metabolism ; Esophageal Neoplasms/*etiology ; Gastroesophageal Reflux/*etiology ; Humans ; Obesity/*complications/pathology ; Peptide Hormones/metabolism/physiology

BACKGROUND/AIMS: The purpose of this study was to estimate the prevalence of Barrett's esophagus (BE) and its association with reflux esophagitis (RE) and peptic ulcer disease detected by free charge endoscopy which was covered by the National Health Insurance at a secondary care hospital, and to compare the results of the biopsy of BE with that of cardiac intestinal metaplasia (CIM). METHODS: A total of 4,002 patients underwent endoscopy from March 2010 to December 2012. BE was diagnosed if there was histologically proven specialized intestinal metaplasia, and CIM was diagnosed if intestinal metaplasia was accompanied with chronic gastritis. RESULTS: Four hundred twenty four patients underwent endoscopic biopsy, and the prevalence of BE was 1.0% (42/4,002). The mean age and the proportion of males in BE were significantly higher than those of the rest of study population, and BE had slight tendency related to RE than the rest of study population. CIM was observed in 34 patients and BE and CIM showed similar results, regarding age, sex and association with RE. The mean length of endoscopic Barrett's mucosa of BE group was 9.2+/-5.1 mm, and it was similar to that of CIM. CONCLUSIONS: The prevalence of BE in the secondary care hospital was not low, and old age and male sex were significantly associated with BE. Because BE was observed in about 10% of biopsied patients and CIM was observed in a similar percentage with BE, the precise targeted biopsy is warranted and the biopsy method should be reestablished through the large prospective study of multiple secondary care hospitals.
Adult ; Aged ; Aged, 80 and over ; Barrett Esophagus/complications/epidemiology/*pathology ; Duodenal Ulcer/complications/epidemiology/pathology ; Esophagoscopy ; Female ; Gastroesophageal Reflux/complications/epidemiology/pathology ; Hospitals ; Humans ; Male ; Metaplasia/complications/epidemiology/*pathology ; Middle Aged ; Prevalence ; Secondary Care ; Stomach Ulcer/complications/epidemiology/pathology

In 2010, a Korean guideline for the management of gastroesophageal reflux disease (GERD) was made by the Korean Society of Neurogastroenterology and Motility, in which the definition and diagnosis of GERD were not included. The aim of this guideline was to update the clinical approach to the diagnosis and management of GERD in adult patients. This guideline was developed by the adaptation process of the ADAPTE framework. Twelve guidelines were retrieved from initial queries through the Appraisal of Guidelines for Research & Evaluation II process. Twenty-seven statements were made as a draft and revised by modified Delphi method. Finally, 24 consensus statements for the definition (n=4), diagnosis (n=7) and management (n=13) of GERD were developed. Multidisciplinary experts participated in the development of the guideline, and the external review of the guideline was conducted at the finalization phase.
Antacids/therapeutic use ; Anti-Ulcer Agents/therapeutic use ; Antidepressive Agents/therapeutic use ; Barrett Esophagus/complications/diagnosis ; Databases, Factual ; Diet ; Dose-Response Relationship, Drug ; Drug Administration Schedule ; Drug Therapy, Combination ; Endoscopy, Digestive System ; Esophageal pH Monitoring ; Gastroesophageal Reflux/complications/*diagnosis/drug therapy ; Histamine Antagonists/therapeutic use ; Humans ; Peptic Ulcer/complications/diagnosis ; Proton Pump Inhibitors/therapeutic use ; Stomach Neoplasms/complications/diagnosis

BACKGROUND/AIMS: Recent studies suggest that the prevalence of gastroesophageal reflux disease (GERD) is increasing in Korea. However, studies on risk factors for GERD have yielded inconsistent results. The aims of this study were to compare clinical features between symptomatic syndromes without esophageal injury (=non-erosive disease [NED]) and syndromes with esophageal injury (=erosive disease [ED]), and to determine risk factors associated ED. METHODS: A total of 450 subjects who visited gastroenterology clinics of six training hospitals in Daegu from March 2008 to April 2010 were consecutively enrolled. The subjects were asked to complete a questionnaire which inquired about gastroesophageal reflux symptoms. The questionnaire also included questions about smoking, alcohol drinking, consumption of coffee, use of drugs, exercise, and other medical history. The subjects were subdivided into NED and ED groups. RESULTS: The proportion of subjects in each NED and ED group was 172 (38.2%) and 278 (61.8%). Male gender, smoking, alcohol drinking, consumption of coffee, large waist circumference, infrequent medication of antacids, aspirin and NSAIDs, infrequent and mild GERD symptoms were all significantly associated with ED on univariate analysis. Age, hiatal hernia, diabetes mellitus, body mass index, change in weight during 1 year, and number of typical GERD symptoms were not independent risk factors for ED. However, the association between ED and alcohol drinking, infrequent medication of antacids, mild typical GERD symptoms remained as strong risk factors after adjustments on multivariate logistic analysis. CONCLUSIONS: Independent risk factors associated with ED were alcohol drinking, infrequent medication of antacids and mild typical GERD symptoms.
Adolescent ; Adult ; Aged ; Alcohol Drinking ; Antacids/therapeutic use ; Anti-Inflammatory Agents, Non-Steroidal/therapeutic use ; Aspirin/therapeutic use ; Barrett Esophagus/complications/diagnosis ; Body Mass Index ; Coffee ; Endoscopy, Gastrointestinal ; Esophagitis, Peptic/complications/*diagnosis ; Female ; Gastroesophageal Reflux/complications/*diagnosis ; Humans ; Logistic Models ; Male ; Middle Aged ; Questionnaires ; Republic of Korea ; Risk Factors ; Severity of Illness Index ; Sex Factors ; Waist Circumference

Adenocarcinoma ; etiology ; metabolism ; pathology ; Barrett Esophagus ; complications ; epidemiology ; etiology ; metabolism ; pathology ; Biomarkers, Tumor ; metabolism ; Biopsy ; CDX2 Transcription Factor ; Esophagogastric Junction ; pathology ; Esophagus ; pathology ; Homeodomain Proteins ; metabolism ; Humans ; Intercellular Signaling Peptides and Proteins ; metabolism ; Keratin-20 ; metabolism ; Keratin-7 ; metabolism ; Mucous Membrane ; pathology ; Precancerous Conditions ; metabolism ; pathology

PURPOSE: It is known that cyclooxygenase (COX)-2 expression is increased in Barrett's esophagus and esophageal adenocarcinomas. We studied COX-2 expression and the effect sulindac has on the genesis of Barrett's esophagus and adenocarcinoma in rats undergoing esophagogastroduodenal anastomosis (EGDA). MATERIALS AND METHODS: Fifty-one rats were divided into a control group (n=27), a 500ppm sulindac-treated group (n=15) and 1000 ppm sulindac-treated group (n=9). Randomly selected rats were killed by diethyl ether inhalation at 20 and 40 weeks after surgery. RESULTS: At 40 weeks, rats treated with 1000 ppm sulindac showed narrower esophageal diameter and milder inflammation than the control rats. At 40 weeks, the incidence of Barrett's esophagus was similar between control and sulindac-treated groups, but the incidence of adenocarcinoma was significantly lower in the 1000ppm sulindac-treated group than either the control or 500 ppm sulindac-treated groups. COX-2 was significantly increased in the lower esophagus of control rats killed at 40 weeks. Cyclin D1 expression was negligible in the sulindac- treated group compared with the control group. CONCLUSION: We suggest that the chemopreventive effect of sulindac is related to decreased COX-2 and cyclin D1 expression, which may be influenced by reduced inflammation.
Adenocarcinoma/etiology/metabolism/*prevention & control ; Animals ; Antineoplastic Agents/therapeutic use ; Barrett Esophagus/etiology/metabolism/prevention & control ; Blotting, Western ; Cyclin D1/metabolism ; Cyclooxygenase 2/metabolism ; Duodenogastric Reflux/*complications ; Esophageal Neoplasms/etiology/metabolism/*prevention & control ; Immunohistochemistry ; Male ; Proliferating Cell Nuclear Antigen/metabolism ; Rats ; Rats, Sprague-Dawley ; Sulindac/*therapeutic use

BACKGROUND/AIMS: The prevalence of gastroesophageal reflux disease (GERD) in Korea was believed to be low until now. Korea is now believed to be on the evolving stage of GERD in its' prevalence. The aims of this study were to evaluate the epidemiologic and clinicopathologic characteristics among the subgroups of GERD i.e. non-erosive GERD (NERD), erosive GERD (ERD) and Barrett's esophagus (BE), and the role of Helicobacter pylori (H. pylori) infection in the pathogenesis of GERD. METHODS: A total of 253 patients with typical symptoms of GERD who underwent EGD were enrolled from October 2002 to January 2004. Patients were grouped as NERD, ERD or BE based on the symptoms and endoscopic findings. BE was histologically confirmed if necessary. Various clinical parameters including the status of H. pylori infection were analyzed. RESULTS: Among 253 patients, 106 patients were classified as NERD while 116 and 31 patients were classified as ERD and BE group respectively. BE and ERD group showed no gender predilection while NERD showed female preponderance (2.31:1, p<0.05). NERD group were younger (49.57 y.o.) than BE (57.87 y.o.) and ERD (52.30 y.o.) group. About three quarters of the patients of erosive esophagitis were LA-A (74.2%) grade. This suggests the mild nature of erosive esophagitis in Korea. ERD showed significantly higher BMI (kg/m2) compared to NERD (p<0.05). Hiatal hernia was frequently associated with BE and ERD (p<0.05), but less frequently in NERD. Overall H. pylori positivity among GERD was significantly lower than the age and gender matched control group (p<0.05). CONCLUSIONS: Subgroups of GERD in Korea showed different epidemiologic and clinical characteristics. Lower rate of H. pylori infection among GERD group may reflect the protective role of H. pylori infection regarding GERD prevalence in Korea.
Aged ; Barrett Esophagus/diagnosis/drug therapy/microbiology ; Female ; Gastroesophageal Reflux/diagnosis/drug therapy/*microbiology ; Helicobacter Infections/*complications/drug therapy/epidemiology ; *Helicobacter pylori ; Humans ; Korea/epidemiology ; Male ; Middle Aged ; Prevalence

BACKGROUND/AIMS: Barrett's esophagus is a premalignant lesion of the esophagus in which normal squamous epithelium is replaced by intestinalized columnar epithelium. In Korea, adenocarcinoma associated with Barrett's esophagus is rare compared with that of Western country. The purpose of this study was to investigate the immunohistochemical expression of p53 and Ki-67 in Barrett's esophagus which had predictive value for cancer risk in Korea. METHODS: Ninety five patients (43 male and 52 female, median age 44, range 21-75) who have been suspected to have Barrett's esophagus by endoscopic assessment were enrolled in this study. Alcian blue (pH 2.5) and high ion diamine stain for the evaluation of specialized intestinal metaplasia (SIM) and immunohistochemical stain for p53 and Ki-67 were done. RESULTS: 57.9% (55/95) of biopsies from the columnar lined esophagus showed SIM, but no dyspalsia. 56.4% (31/55) of Barrett's esophagus showed sulfomucin positive colonic metaplasia. The p53 expression was observed in 10.9% (6/55) of the patients of Barrett's esophagus and all of them showed colonic metaplasia. Ki-67 labeling index showed no difference significantly. CONCLUSIONS: In Korea, 10.9% of Barrett's esophagus had p53 mutation and moreover all of them had colonic metaplasia. Consequently, we expect that these patients have high risk of developing dysplasia and adenocarcinoma and need careful follow-up.
Adenocarcinoma/etiology/genetics ; Adult ; Aged ; Barrett Esophagus/complications/*metabolism ; Esophageal Neoplasms/etiology/genetics ; Female ; Humans ; Immunohistochemistry ; Ki-67 Antigen/*metabolism ; Male ; Middle Aged ; Risk Factors ; Tumor Suppressor Protein p53/*metabolism

To determine the relationship between Barrett's esophagus (BE) and features of gastroesophageal acid reflux, 24 h esophageal pH monitoring was performed in 90 patients. The patients were divided into 3 groups: 31 subjects with BE, 21 with mild esophagitis and 38 with severe esophagitis. The following parameters were evaluated: the percentage time of pH < 4; the number of reflux episodes over 5 min; the duration of longest episodes and DeMeester score over total period and the auterior three parameters in erect and supine position. All these parameters in BE were significantly different from those with mild esophagitis (P < 0.01) and not significantly different from those with severe esophagitis (P > 0.05). During supine position all the above parameters in BE were significantly different from those with reflux esophagitis (P < 0.05). It is concluded that the quantity of acid reflux is not an important factor in development of BE in gastroesophageal reflux (GER), and the acid reflux in supine position might be important in development of BE in GER.
Adult ; Barrett Esophagus ; etiology ; physiopathology ; Esophagitis, Peptic ; etiology ; Female ; Gastroesophageal Reflux ; complications ; Humans ; Hydrogen-Ion Concentration ; Male ; Middle Aged ; Supine Position