Abstracts
S1161
Clinical Significance of Magnifying Endoscopy Combined with
the Narrow Band Imaging System for Barrett’s Esophagus
Ken-ichi Goda
Background: Specialized intestinal metaplasia (SIM), which distributes patchily
within Barrett’s esophagus (BE), has been detected by random or four quadrant
biopsy using conventional endoscopy. However, little is known about the fine
mucosal structure of SIM using magnifying endoscopy. Magnifying endoscopy
combined with the narrow-band imaging (NBI) system is a novel technique, which
yields very clear images of not only fine mucosal patterns without using dye spray
(chromoscopy) but also capillaries on the mucosal surface. Aim: We studied the
diagnostic utility of SIM and adenocarcinoma in BE, using magnifying endoscopy
combined with the NBI system. Method: Patients with BE were studied with
magnifying endoscopy (GIFQ240Z) combined with the NBI system (Olympus
Tokyo, Japan). Categorized fine mucosal patterns and capillary patterns were
identified, biopsied and read by the pathologist blinded to endoscopic findings.
Result: During December 2003 and August 2004, 50 patients (43 men, 7 women)
with BE have been included in the study. A mean age was 64 years (range: 40-70)
and a mean length of BE was 23 mm (range: 5-130). Magnifying endoscopic findings
for 189 regions in BE were recorded and compared with histological findings of
biopsy specimens. Fine mucosal structure was classified into 5 patterns; round or
oval, straight, villus, cerebriform and irregular, and additionally capillary patterns
into five categories of Type I (honeycomb-like pattern), Type II (,zently tortuous
pattern), Type III (coil or curly-hair like pattern), Type IV (intertwining pattern with
a connection), Type V (abnormal pattern showing irregular running and
heterogeneous shapes). Fine mucosal patterns showing ‘‘villus’’ or ‘‘cerebriform’’
detected SIM with a sensitivity of 85% for histological findings (accuracy 58%). Type
IV was peculiar to the histological region of SIM (specificity 94%, accuracy 89%).
‘‘Irregular’’ fine mucosal pattern and Type V capillary pattern were characteristic
features of Barrett’s adenocacinoma in the early stage. Conclusion: Magnifying
endoscopy combined with the NBI system provides detail images of the fine
mucosal and capillary patterns in BE. In this study, we suggest that capillary
patterns are more useful for the detection of SIM in BE than fine mucosal patterns.
We also believe that magnifying endoscopy combined with the NBI system enables
us to detect and recognize the demarcation line of Barrett’s adenocarcinoma in the
early stage.
S1162
Eosinophilic Esophagitis (EE) in Adults: Emerging Entity or
Misdiagnosed Malady
Nirmala Gonsalves, Peter J. Kahrilas, Ikuo Hirano
EE has been increasingly recognized as an important cause of dysphagia and food
impaction in adults. Endoscopic therapy of food impactions and strictures in EE has
been associated with esophageal tears and perforation. Our goal was to review
demographic and endoscopic findings of our cohort of 74 adult patients (pts) to
better understand the clinical course of this illness. Methods: We conducted a chart
review of pts seen between 1999 and 2004 with a diagnosis of EE based on at least
15 eosinophils per high powered field. Demographic, endoscopic and histologic
data were collected. Results: 74 pts were included in this analysis, the largest adult
series studied to date. The mean pt age was 38 yrs (14-76) with a mean duration of
symptoms of 6.9 yrs (.5-20). 57 pts (76%) were male. The most common presenting
symptoms were dysphagia (90%), food impaction (55%) and heartburn (31%). 53%
of pts had been to the emergency room with food impactions requiring endoscopic
removal. 43% of pts had previous endoscopies an average of 5 yrs (.5-23) prior to
their diagnosis of EE. The most common initial diagnosis in this group were
Schatzki’s rings (SR) (37%), esophageal strictures/webs (26%), reflux (22%), peptic
strictures (11%) and congenital esophageal stenosis (4%). 88% of cases were
diagnosed with EE after 2003. 20% of pts had bx initially read as GERD and
subsequently changed to EE on repeat histologic review. 70% of pts had an allergic
history; 77% having seasonal allergies, 17% having combined seasonal and food and
7% with allergic skin conditions. Of pts with a complete blood count, only 9% had
a peripheral eosinophilia. The most common endoscopic findings were mucosal
rings (81%) and linear furrows (74%) followed by strictures (31%), exudates (15%),
small caliber (10%) and edema (8%). Incidental findings of hiatal hernia, SR and
esophagitis were seen in 45%, 16% and 16% respectively. 50% of pts were treated
with dilation using CRE balloon (70%), Savory (16%) and a combination of methods
(8%). Conclusions: (1) 43% of pts had endoscopies for dysphagia with diagnoses
other than EE an average of 5 years prior, likely representing misdiagnoses. (2) The
majority of pts were diagnosed after 2003 suggesting increased recognition by
gastroenterologists and pathologists. (3) Better recognition of EE should allow
earlier medical treatment that may reduce the need, and thereby prevent
complications associated with endoscopic procedures for EE.
AB132 GASTROINTESTINAL ENDOSCOPY Volume 61, No. 5 : 2005
S1163
Inter- and Intraobserver Variability in High Resolution
Chromoendoscopy with Acetic Acid for the Detection of
Intestinal Metaplasia and Early Neoplasia in Barrett’s Esophagus
Liebwin Gossner, Oliver Pech, Andrea May, Thomas Rabenstein,
Hendrik Manner, Angelika Behrens, Christian Ell
Specialized intestinal metaplasia (SIM) in Barrett’s esophagus (BE) embodies the
risk of malignant transformation. Optically guided, ‘‘smart’’ biopsies using
chromoendoscopy with acetic acid (AA) are a fascinating option in surveillance
procedures for BE. Methods: Consecutive patients with GERD, suspicious of SIM or
early neoplasia in BE referred to our center were enclosed in this prospective study.
They were studied using Fujinon high resolution endoscopes (EG HR485ZW5, EG
HR490ZW5). The distal esophagus was sprayed with a solution of 1.5% acetic acid.
Esophageal columnar mucosal patterns were characterized after AA spraying:
Dotted round pits representing cardiac mucosa (pattern I), villous and ridged
surface pattern (pattern II) for SIM and an irregular, distorted mucosal pattern
(pattern III) representing neoplasia in SIM. The observed surface patterns were
digitally stored on PC. All digitally stored images were reassessed by 6 blinded
endoscopists. Intra- and interobserver variations of the investigators were evaluated
by using kappa statistics. Results: 394 endoscopic pictures of 96 patients were
studied. SIM could be predicted with a sensitivity of 92%, high-grade intraepithelial
neoplasia (HGIN) or early mucosal cancer in 89% respectively. The mean kappa for
interobserver agreement was 0.959, whereas intraobserver agreement showed
a mean kappa of 1.0. Conclusions: High resolution endoscopy with acetic acid is an
accurate method for visually predicting SIM and early neoplasia in BE with very low
inter- and intraobserver variability.
S1164
Accuracy of Macroscopic Classification of Early Barrett’s Cancer:
Prospective Data From the Wiesbaden Barrett’s Register
Liebwin Gossner, Oliver Pech, Andrea May, Hendrik Manner,
Thomas Rabenstein, Angelika Behrens, Christian Ell
So far, there exists no standardised macroscopic classification of early cancer in
Barrett’s esophagus (BC). Therefore, BC is classified according to the Japanese
classification of early gastric cancer. No prospective data are available whether this
classifcation can be transferred to Barrett’s neoplasia, its diagnostic accuracy and
interobserver variability. Patients & Methods: All patients refered to our hospital for
endoscopic therapy of early Barrett’s cancer were endoscopically classified
according to their macroscopic type: polypoid tumor (type I), flat and slightly
elevated (IIa), flat and level (IIb), flat depressed (IIc), and ulcerated (III) were
documented according to the Japanese criteria for early gastric cancer. These data/
digital images were documented prospectively in an electronic database. All
digitally stored images were reassessed by 6 blinded endoscopists. Intra- and
interobserver variations of the investigators were evaluated by using kappa
statistics. Results: 416 neoplastic lesions (high grade dysplasia (HGD) (n Z 32),
mucosal (n Z 343) or submucosal (n Z 41)) were included and documented. The
distribution of the macroscopic type was as follows: Type I n Z 54 (13%); IIa n Z
152 (36.5%); IIb n Z 117 (28%); IIc n Z 17 (4%); IIaCc n Z 69 (16.5%); III n Z 7
(2%). The mean kappa for interobserver agreement for the involved endoscopists
(AB, AM, OP; HM, TR, LG) was 0.865 (range: 0.672-1.0), wheras intraobserver
agreement showed a mean kappa of 0.891 (range: 0.812-1.0). Less experienced
endoscopists showed a higher inter- and intraobserver variability. Conclusion: This
first analysis of the macroscopic type of early Barrett’s neoplasia demonstrates that
BC can reliably be classified according to its macroscopic endoscopic appearance
with low inter- and intraobserver variability. This macroscopic classification may be
of crucial clinical importance for detecting and diagnosing early cancer in Barrett’s
esophagus.
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