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Julio Alejandro Murra-Saca MD.
Gastroenterologist,
Tel : (503) 226-3131, (503) 225-3087, Celular (503) 887-2507
Email
   
Edificio Centro Scan, Colonia Médica, San Salvador, El Salvador.

 

New: See below the Flexible endoscopic Suturing Device. Endoscopic Anti-Reflux Procedure.
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Notes on Cyber Gastroenterology

 

Gastroesophageal Reflux Disease (GERD)
This frequent ailment is consequence of the abnormal passage of stomach contents into the esophagus. It is one of the most common afflictions seen in daily gastro-intestinal practice.

Heartburn results from gastroesophageal reflux, a condition in which stomach acids back up into your esophagus. You feel a burning pain behind your breastbone, often accompanied by a sour taste and the sensation of food coming back into your mouth.

Normally, acid is trapped in your stomach by a circular band of muscle between the esophagus and stomach called a sphincter. The sphincter remains closed except when you swallow. If the sphincter relaxes abnormally or weakens, stomach acid tends to back up, causing symptoms of heartburn.

 

Gastro-esophageal reflux is a disorder of the motility of the g.i.tract, the motility being described as the interaction of normal bowel movements of the digestive tract. In gastro-esophageal reflux the sphincter between the two aforementioned organs is adversely affected, its tone being diminished which leads to incompetency and incomplete closure. This leads to the retrograde passage of gastric acid and pepsin into the esophagus with ensuing irritation of the mucosa This condition gives origin to a wide variety of symptoms, which range from asymptomatic states to severe retro-sternal pain, which may mimic life threatening cardiovascular disease. Other symptoms include retro-sternal burning or pain.
Heartburn is virtually always due to reflux of acidic gastric contents into the esophagus. Transient lower esophageal sphincter relaxations (tLESRs) often underlie both normal and pathological reflux. In healthy individuals, gravity and peristalsis rapidly clear refluxate, whereas swallowed saliva neutralizes remaining adherent esophageal acid. Heartburn occurs when these protective mechanisms and/or endogenous mucosal defenses are impaired. Other etiologic factors include an increased frequency of inappropriate tLESRs and prolonged acid contact time.Fore more endoscopic details please download the video clip  by  clciking on the image
Endoscopic Image of a ulcer caused by a gastroesophageal reflux, retroflex maneuver. For more endoscopic details please download the video clip by clicking
on the image, wait to the time of download and press Alt and Enter to appreciate
in full screen.

 
Complications of GERD.

 

Flexible Endoscopic Suturing Device.

A new device, Flexible endoscopic Suturing Device. Endoscopic Anti-Reflux Procedure, Gastroesophageal reflux disease (GERD) is a result of exposure of the lining of the esophagus to the contents of the stomach, which is usually acidic in nature. Medical therapy of GERD usually consists of medications that reduce acid secretion or improve gastric emptying and have been shown to be effective in the majority of patients. Patients who do not respond or are unable to tolerate medical therapy may be candidates for anti-reflux procedures that can be performed either by surgery or by endoscopy.
T he ESD Flexible Endoscopic Suturing device
Facilitating beneficial therapeutic intervention with minimal discomfort, this supple, flexible product enables the closure of wound sites that would otherwise be inaccessible without violating the integrity of the patient's digestive tract, skin, or other protective structures. The device is suited for use on sites within 70 cm of the mouth or anus, and does not require general anaesthesia or leave painful secondary wounds. Enabling novel procedures, the ESD device also may reduce the need for postoperative patient medication and speeds the conversion of existing surgical procedures to minimally invasive techniques.
The ESD Flexible Endoscopic Suturing device. It uses the same principal of tightening the junction between the esophagus and the stomach by the placement of sutures. This device has been approved by the FDA and is being studied for the treatment of GERD.

La Sutura Endoscópica
This picture displays the new device, The ESD Flexible Endoscopic Suturing device.

 

La Sutura endoscópica
 
La Sutura Endoscópica.
 
For more endoscopic details download the video clip by clicking on the endoscopic images.
More details download the video clip.
For more endoscopic details download the video clip by clicking on the endoscopic images.
Endoscopic Sequence 1 of 11.

FLEXIBLE ENDOSCOPIC SUTURING DEVICE
Endoscopic Suturing due to chronic gastroesophageal reflux The image and the video display a retroflexed hiatal hernia.
35 year-old male, who has been medical record of suffering refracting Gastro Esophageal Reflux Disease (GERD)
Since 4 years.
For more endoscopic details download the complete sequence of video clips by clicking on the endoscopic
images.
For more endoscopic details download the video clip by clicking on the endoscopic images.
Endoscopic Sequence 2 of 11.
Suturing System and standard video endoscopy, sutures are placed in the upper part of the stomach at or just below the LES. Two stitches can be placed and tied together to create a pleat near the LES and treat symptomatic reflux.
The image and the video clip display a flexible suturing device which has been passed through the external
accessory channel, with a friction-fit adapter and tube guide, provides a pathway for the flexible endoscopic
suturing device.

For more endoscopic details download the video clip by clicking on the image.

For more endoscopic details download the video clip by clicking on the endoscopic images.
Endoscopic Sequence 3 of 11.

The ESD Flexible Endoscopic Suturing device. It uses the same principal of tightening the junction between the esophagus and the stomach by the placement of sutures. This device has been approved by the FDA and is being studied for the treatment of GERD. The image and the video display the step of sucking
enough tissue (mucosa, sub mucosa and muscularis). The needle is then fired into the sucked tissue.
We applied the first suture with the first needle and at the same time we removed the valve of suction and in this way it free the tissue from the pincer and we prepared the field for the second suture which is one centimeter away from the first one.

For more endoscopic details download the video clip by clicking on the image
For more endoscopic details download the video clip by clicking on the endoscopic images.
Endoscopic Sequence 4 of 11.

The image and the video clip display to loosen the tissues, certain maneuver are observed we prepared the second suture one centimeter away from the first one. In the image observed the process after the tissue which we deliver one suture, with this device. We observed the threads through the cardias and then, we applied the second suture to one centimeter away from the first one. We look the 4 threads that convert to
two with applied traction that is direct out and both tissues gathered.

For more endoscopic details download the video clip by clicking on the endoscopic images.
Endoscopic Sequence 5 of 11.

We prepared the second suture one centimeter away from the first one. In the image observed the process after the tissue which we deliver one suture, with this device. We observed the threads through the cardias and then, we applied the second suture to one centimeter away from the first one.
For more endoscopic details download the video clip by clicking on the endoscopic images.
Endoscopic Sequence 6 of 11.

We look the 4 threads that convert to two with applied traction that is direct out and both tissues gathered
together.


For more endoscopic details download the video clip by clicking on the endoscopic images.
Endoscopic Sequence 7 of 11.

The image and the video displaying both threads that were observed as four this is becaouse they have been
traccioned outwards. In the image show two threads that previously were four, but after we applied outside traction and the cardia's tissue is suture and close to each other the next step is to tie between the sutures and we use other special pince wich we thread the needle in this pincer with a titanium's clip. And we gaze the other flexible pince wich has the threads attach with a titanium's clip.

For more endoscopic details download the video clip by clicking on the endoscopic images.
Endoscopic Sequence 8 of 11.

The next step is to perform the knot, The titanium knot mechanically fastens suture together and
cuts away excess suture. And those threads position close to the mouth and out from
the patient are introducing to other special pince which is
flexible to attach a titanium's clip.

For more endoscopic details download the video clip by clicking on the endoscopic images.
Endoscopic Sequence 9 of 11.

For more endoscopic details download the video clip by
clicking on the endoscopic images.

For more endoscopic details download the video clip by clicking on the endoscopic images.
Endoscopic Sequence 10 of 11

In this step this clamp is withdrawn, the hole of the clamp is observed where the titanium knot is applied and
the threads are cut, also this clamp is equipped to cut threads.

 

For more endoscopic details download the video clip by clicking on the endoscopic images.
Endoscopic Sequence 11 of 11.

The knot is observed, the threads and the titanium clip The first stich is finish of this form increase the pressure of the inferior gastroesophageal sphincter, this procedure is simple, two to four stitches are required according to the size of the hiatal hernia. This endoscopic procedure is practical, safe and mainly the
because the patient benefits due the gastroesophageal reflux disappears.
Hernia del hiato de tamaño grande. Se observa la sutura endoscópica. Se observa la unión de los tejidos por la sutura endoscópica.  
51 year-old male with hiatus hernia and heart burning since 3 years.
An endoscopic gastroplicature was performed. The treatment is delivered via an endoscope.
final status from a Endoscopic Anti-Reflux Procedure was archived that is done on an outpatient basis patient go home the same day.
 
   
24 year-old female who has been
suffered of Gastroesophageal Reflux Disease (GERD) since 8 years even with PPI.
She has incompetence of the inferior gastroesophageal sphincter.
Another image of the inferior gastroesophagic junction.
A flexible device with treads is

shown, the tip of flexible endoscopic (flexible Sew-Right Device).
The clamp with threads is suctioning the gastroesophageal
junction.
The image and the video clip display the traction exerted
by the treads that tied the tissues.
The gastroplication has been completed.
Plication techniques create a mechanical barrier to reflux
through apposition of 2 mucosal surfaces at the
gastroesophageal junction or in the cardia.
Final statust of the endoscopic gastroplicature.
Patient relief the symptoms.
Final statust of the endoscopic gastroplicature.
Patient relief the symptoms.

 

 

To appreciate another sequences of images and videos of Flexible Endoscopic Suturing, Endoscopic Anti-Reflux Procedure, press here.
 
 
 
 
 
 
 
Fore more endoscopic details please download the video clip  by  clciking on the image
Endoscopic view of reflux esophagitis.
Fore more endoscopic details please download the video clip  by  clciking on the image
Reflux Esophagitis, radial ulcers and hiatus hernia are
observed.
Many patients with GERD have a normal esophagus on
endoscopy. The first sign of esophageal damage may be
erythema. Appearance of erosions indicates more severe
disease. Deep esophageal ulcers can occur in addition to
the more common shallow erosions. As its severity
increases, esophagitis can lead to obstruction through
stricture formation. Severe esophagitis can also lead to
cancer through the development of a columnar lining
known as Barrett's esophagus.

 

Fore more endoscopic details please download the video clip  by  clciking on the image
Severe esophagitis is appreciated by the presence
of several, confluent erosions and whitish exudate
on the mucosa. A hiatal hernia is observed .

 

Fore more endoscopic details please download the video clip  by  clciking on the image
Severe reflux esophagitis, in retroflexion view.
An ulcerated cardias is observed.


Barrett's Esophagus

 

Barrett's esophagus is usually discovered during endoscopic examinations of middle-aged and older adults whose mean age at the time of diagnosis is approximately 55 years . Although Barrett's esophagus can affect children, it rarely occurs before the age of five . This observation supports the contention that Barrett's esophagus is an acquired condition, not a congenital one. Barrett's esophagus appears to be uncommon in blacks and Asians. The prevalence in Hispanics is similar to Caucasians.

The columnar metaplasia in Barrett's esophagus causes no symptoms. Thus, most patients are seen initially for symptoms of the associated GERD such as heartburn, regurgitation, and dysphagia..

Barrett's esophagus is a precancerous condition of the esophagus that typically affects white males over 50 years although others may also have this condition. The incidence of the type of cancer associated with Barrett's esophagus has recently dramatically increased.
GERD associated with Barrett's esophagus frequently is complicated by esophageal ulceration, stricture, and hemorrhage Some studies have suggested that patients with a peptic stricture have a higher prevalence of Barrett's esophagus than those without strictures. This relationship is not surprising since both peptic stricture and Barrett's esophagus are associated with more severe GERD. However, this association has been challenged in study of patients referred for endoscopy for GERD in whom the prevalence of intestinal metaplasia was the same in patients with and without strictures.
DIAGNOSTIC CRITERIA There has been intense controversy regarding the diagnostic criteria for Barrett's esophagus. The deceptively simple, conceptual definition of the disorder as a condition in which columnar epithelium replaces squamous epithelium in the distal esophagus does not translate easily into practical diagnostic criteria, primarily because there are no reproducible landmarks that clearly delimit the end of the esophagus. The esophagogastric junction has been defined differently by anatomists, radiologists, physiologists, and endoscopists, and the location of the junction identified by these different criteria may vary by several centimeters or more
Columnar epithelium, with its reddish color and velvet-like texture, can be distinguished readily from the pale, glossy squamous epithelium of the esophagus on endoscopic examination. It can appear as tongues extending from the squamocolumnar junction, continuous areas extending into the distal esophagus, or discrete islands within normal appearing squamous mucosa. Heterotopic gastric mucosa with a similar appearance can be seen on occasion in the proximal 3 cm of the esophagus, frequently immediately below the upper esophageal sphincter (an "inlet patch"). The majority of such cases are clinically insignificant, although rare complications (tracheoesophageal fistula, an increased risk of peptic esophagitis from biopsies obtained near the patch, adenocarcinoma arising from within the patch, and cervical webs and rings) have been described.

Three different terms have been used to describe the presence of intestinal metaplasia in the esophagus:

Long segment Barrett's esophagus

Short segment Barrett's esophagus

Junctional intestinal metaplasia


These definitions are based upon two anatomic landmarks seen on endoscopy: the squamocolumnar junction, and the esophagogastric junction.

The squamocolumnar junction is the border between the squamous lined epithelium of the esophagus and the columnar epithelium of the stomach (also referred to as the "Z line").

The esophagogastric junction is the border between the esophagus and the stomach. It is usually recognized during endoscopy by appreciation of where the proximal gastric folds end and the tubular esophagus begins. The Z line is normally located within 2 cm of the proximal edge of the gastric folds. The length of intestinal metaplasia between the esophagogastric junction and the squamocolumnar junction represents the extent of Barrett's esophagus. However, recognition of these landmarks can be difficult, particularly in patients who have hiatal hernia, which is usually present in patients with Barrett's esophagus. Furthermore, intestinal metaplasia may not always be apparent on endoscopy. In one study, the positive predictive value of endoscopy for the presence of intestinal metaplasia was only 34 percent; correct diagnosis was more likely in patients with long segment Barrett's esophagus.

Long segment Initial investigations of Barrett's esophagus established arbitrary criteria for the extent of esophageal columnar lining necessary to include patients in studies. Published diagnostic criteria varied substantially, ranging from as few as 2 cm to as many as 5 cm of columnar lined esophagus. Many authorities have now settled on 3 cm as the cutoff for long segment Barrett's.

These arbitrary criteria, designed specifically by investigators for use in clinical trials, were adopted into clinical practice. By adhering to these diagnostic criteria, clinicians limited the problem of false-positive diagnoses, but failed to recognize short segments of metaplastic epithelium in the distal esophagus.

Short segment Diagnostic difficulties arise in patients who have short segments of columnar epithelium that appear to be confined to the distal esophagus. Without precise landmarks for the esophagogastric junction, it can be difficult to determine whether these short segments of columnar epithelium line the distal esophagus or whether they line a tubular segment of the gastric cardia that the endoscopist has mistakenly identified as esophagus. Some authorities have proposed that the term "short-segment Barrett's esophagus" should be used in patients who have less than 2 to 3 cm of specialized intestinal metaplasia lining the distal esophagus.

Junctional intestinal metaplasia To further complicate matters, intestinal metaplasia can exist below the squamocolumnar conjunction. When the esophagogastric junction and the squamocolumnar junction are in the same location it is referred to as specialized intestinal metaplasia of the squamocolumnar junction or junctional specialized columnar epithelium. Specialized intestinal metaplasia of the squamocolumnar junction has been linked to adenocarcinoma of the gastric cardia and distal esophagus. However, its relationship to GERD is uncertain.

To overcome these problems with definitions, some authorities have proposed that the diagnosis of Barrett's esophagus should be based solely upon the presence of specialized intestinal metaplasia, not upon any specific extent of esophageal columnar lining. Others have suggested that the term Barrett's esophagus should be eliminated altogether, and that the condition should be called simply "columnar-lined esophagus. Unfortunately, even these approaches have not eliminated diagnostic difficulties.

A major consideration with defining Barrett's esophagus solely by the presence of specialized intestinal metaplasia relates to the high frequency with which short segments can be found in the distal esophagus and its uncertain relationship to malignant transformation and reflux. In one report, for example, short, inconspicuous segments of intestinal-type epithelium were found in the region of the esophagogastric junction in approximately 20 percent of patients in a general endoscopy unit who underwent protocol biopsies, many of whom had no signs or symptoms of gastroesophageal reflux disease (GERD). These observations have been confirmed by a number of subsequent reports.

Most studies on Barrett's esophagus have exclusively included patients with the endoscopically-obvious condition in which the distal esophagus is lined extensively by metaplastic, intestinal-type epithelium. Until the debate over terminology is resolved, the term Barrett's esophagus should be used to refer to such patients.

Differences between long and short segment Barrett's — As discussed above, the prevalence of short segment is much higher than long segment Barrett's esophagus. Both conditions are diagnosed most frequently in patients between the ages of 55 and 65 and are predominantly seen in male Caucasians. Patients with junctional intestinal metaplasia are a possible exception; an equal gender distribution has been reported in this group of patients.

These observations were illustrated in a study that included 889 patients undergoing upper endoscopy who had protocol biopsies obtained at the esophagogastric junction. The overall prevalence of specialized intestinal metaplasia was 13.2 percent with the following distribution:

Long-segment — 1.6 percent

Short segment — 6.4 percent

Intestinal metaplasia of the esophagogastric junction — 5.6 percent.


Patients with long and short segment Barrett's were predominantly male, white smokers. Patients with short segment Barrett's had a shorter history of heartburn. In contrast, those with intestinal metaplasia of the esophagogastric junction had a similar gender distribution and were more likely to be infected by Helicobacter pylori.

The degree and mechanism of acid exposure in patients with short and long segment Barrett's esophagus suggest that patients who develop long segments Barrett's were predisposed to more severe reflux.

Patients with long segment Barrett's tend to have upright and supine reflux in contrast to those with short segment Barrett's who have predominantly upright reflux.

Proximal esophageal acid exposure is more common in patients with long segment Barrett's.

Compared to patients with long segment Barrett's, those with short segments tend to have higher LES pressures and increased distal esophageal peristaltic amplitudes.

Endoscopic Image of Barrett's Esophagus.

 

When to use endoscopy.
The aim of endoscopic screening and surveillance is to both identify Barrett's esophagus and detect early neoplastic changes, defined as dysplasia. The goal of such monitoring is to improve early recognition of invasive esophageal cancer, presumably at a curable stage.

Before endoscopic and biopsy screening is undertaken in a patient with GERD, symptoms should be treated and the patient should be in symptomatic remission. The three main reasons for this approach are as follows:

Endoscopic examination is a screening tool for detection of Barrett's esophagus and not GERD.
One third to one half of patients who have untreated symptoms of GERD have erosive esophagitis, which makes diagnosis of underlying Barrett's epithelium challenging. Often these patients need to be treated with high-dose proton pump inhibitor therapy for 8 weeks, followed by repeat endoscopy.
If Barrett's esophagus is suspected in patients who have active esophagitis, biopsies may be inaccurate because of uncertainty about whether the cause of reactive cellular changes is inflammation or true dysplasia.

Surveillance techniques.
Once inflammation related to GERD is controlled and endoscopic diagnosis of Barrett's esophagus is established, current guidelines recommend obtaining four-quadrant jumbo biopsies at 2-cm intervals. The rationale for comprehensive surveillance stems from observations that dysplasia may be focal and that high-grade dysplasia and early carcinoma in Barrett's esophagus can occur in the absence of endoscopic abnormalities.

Dysplasia is a pathologic diagnosis and is graded as negative, indefinite, positive for low-grade or high-grade changes, or characteristic of intramucosal carcinoma. If a biopsy specimen is labeled negative for dysplasia, the glandular architecture is intact and shows a normal cellular nuclear-to-cytoplasmic ratio. Biopsy samples labeled indefinite for dysplasia include those in which the architecture is moderately distorted but nuclear abnormalities are less marked than with dysplasia. Features such as nuclear stratification, diminished mucus production, or increased cytoplasmic basophilia may be present. The indefinite category is reserved for cases in which changes are too marked to be classified as negative but insufficient for diagnosis of dysplasia.

The histologic diagnosis of low- or high-grade dysplasia is based on the severity of architectural distortion and cytologic criteria that reflect neoplastic transformation of the columnar epithelium. Abnormalities include branched, crowded, and irregularly shaped glands with marked variation in nuclear features, increased nuclear-to-cytoplasmic ratio, increased mitoses, and hyperchromatism..

Intramucosal adenocarcinoma is defined histologically as carcinoma that has moved through the basement membrane into the lamina propria mucosae but has not invaded the submucosa. Generally, biopsies--even jumbo biopsies--are not deep enough to rule out submucosal invasion, and further staging, usually with endoscopic ultrasound, is required.

The direct costs of surveillance can be substantial. Moreover, the appropriate interval of surveillance is still controversial. Generally, surveillance every 2 to 3 years is considered adequate for patients who have no evidence of dysplasia . When low-grade dysplasia is present, the interval is shortened to every 6 months for 1 year, followed by annual surveillance. If high-grade dysplasia is detected on biopsy, the findings should be confirmed by an expert histopathologist. When the confirmation is consistent with high-grade dysplasia, surveillance every 3 months is appropriate if esophageal resection is declined by the patient or is not performed because of other medical considerations.

Treatment of Barrett's Esophagus.
Best Treatment is Prevention
In most cases, Barrett's esophagus cannot be treated effectively. Treatment, as such, starts with controlling GERD and preventing Barrett's from developing. Drugs that block production of acid and relieve irritated tissue are frequently prescribed. It is also beneficial to make lifestyle changes and take self-care steps. These include:

Getting more exercise
Losing weight
Avoiding foods that aggravate heartburn
Stopping smoking
Taking antacids
Elevating the head of the bed to prevent reflux during sleep

Proton pump inhibitors are now considered the cornerstone of therapy for symptomatic GERD. However, there is little data to support the theory that use of proton pump inhibitors, even in high doses, causes clinically significant regression of Barrett's epithelium. Moreover, it is less clear whether asymptomatic patients should be treated with proton pump inhibitors if Barrett's esophagus is diagnosed incidentally. Currently, there is a paucity of data to suggest that normalization of acid exposure decreases the risk of dysplasia and adenocarcinoma.

Antireflux surgery also alleviates the symptoms of GERD, but long-term follow-up studies have not demonstrated a significant regression of Barrett's esophagus after surgery. Certainly, complete regression is uncommon, and even "partial" regression, referring to a decrease in the length of the Barrett's esophagus segment, may be misleading .. Other studies have suggested that antireflux surgery was associated with a reduced risk of dysplasia. However, this may have been due to sampling error and the transient nature of dysplasia, especially low-grade dysplasia.
Other experimental strategies for eliminating Barrett's esophagus, such as thermal ablation and photodynamic therapy are based on the principle that long-term regression may require reinjury of the metaplastic epithelium, followed by regeneration of normal squamous epithelium. Thermal ablation using multipolar electrocoagulation, argon plasma coagulation, and laser therapy ablation are all feasible in the sense that they are minimally invasive and cause less morbidity and mortality than surgery. Nevertheless, although these techniques may initially eliminate much or all of the Barrett's epithelium, it appears that residual intestinal metaplasia may remain under the new squamous epithelium. Moreover, the value of these procedures in patients who have low- or high-grade dysplasia is unclear

 

Surveillance for Dysplasia and Cancer
Periodic endoscopic examinations to look for early warning signs of cancer are generally recommended for people who have Barrett's esophagus. This approach is called surveillance. When people who have Barrett's esophagus develop cancer, the process seems to go through an intermediate stage in which cancer cells appear in the Barrett's tissue. This condition is called dysplasia and can be seen only in biopsies with a microscope. The process is patchy and cannot be seen directly through the endoscope, so multiple biopsies must be taken. Even then, it can be missed.

The process of change from Barrett's to cancer seems to happen only in a few patients, less than 1 percent per year, and over a relatively long period of time. Most physicians recommend that patients with Barrett's esophagus undergo periodic surveillance endoscopy to have biopsies. The recommended interval between endoscopies varies depending on specific circumstances, and the ideal interval has not been determined.

If a person with Barrett's esophagus is found to have dysplasia or cancer, the doctor will usually recommend surgery if the person is strong enough and has a good chance of being cured. The type of surgery may vary, but it usually involves removing most of the esophagus and pulling the stomach up into the chest to attach it to what remains of the esophagus. Many patients with Barrett's esophagus are elderly and have many other medical problems that make surgery unwise; in these patients, other approaches to treating dysplasia are being investigated.

 

Barrett's Esophagus and Cancer of the Esophagus.
The presence of Barrett's esophagus is associated with increased risk of developing an invasive cancer (adenocarcinoma). Columnar epithelial dysplasia as seen in Barrett's esophagus is a premalignant lesion for adenocarcinoma. Adenocarcinoma does not develop "out of the blue". Instead, adenocarcinoma in Barrett's esophagus develops in a sequence of changes, from nondysplastic (metaplastic) columnar epithelium, through low-grade and then high-grade dysplasia (preancerous change detected under the microscope) and finally invasive cancer. This makes early detection and early treatment a possibility.
Patients with Barrett's esophagus have a 30- to 100-fold increased risk of the development of esophageal cancer in comparison with the general population. The disease is most common in white males.


Schatzki Ring

Background: Since the 1950s, several investigators have published reports of patients with dysphagia who had associated lower esophageal ringlike constrictions, but each investigator had a different opinion as to the cause and nature of these rings. In 1953, Ingelfinger and Kramer believed that these rings occurred as a result of a contraction by an overactive band of esophageal muscle; however, Schatzki and Gary believed that these rings were fixed and not contractile. Some of this controversy may be related to the confusion of categorizing muscular and mucosal rings under the same entity, as concluded by Goyal et al.

Two rings have been identified in the distal esophagus. The muscular ring, or A ring, is a thickened symmetric band of muscle that forms the upper border of the esophageal vestibule and is located approximately 2 cm above the gastroesophageal junction. The A ring is rare; furthermore, it is even more rarely associated with dysphagia. On the other hand, the mucosal ring, or B ring, is quite common and is the subject of discussion in this article. The B ring is a diaphragmlike thin mucosal ring usually located at the squamocolumnar junction; it may be symptomatic or asymptomatic, depending on the luminal diameter.

The pathogenesis is not clear, and patients typically present with intermittent nonprogressive dysphagia for solids. Fortunately, most patients respond well to initial and repeat dilatation therapy. A small number of patients may have stubborn rings that require more aggressive endoscopic or surgical intervention.

Pathophysiology: The pathogenesis of Schatzki rings is not clear, and at least 4 hypotheses have been proposed. These hypotheses may not be mutually exclusive. Proposed hypotheses are as follows:


The ring is a pleat of redundant mucosa that forms when the esophagus shortens transiently or permanently for unknown reasons.

The ring is congenital in origin.

The ring is actually a short peptic stricture occurring as a consequence of gastroesophageal reflux disease.

The ring is a consequence of pill-induced esophagitis.

Endoscopic image of Schatzki ring.
Endoscopic image of Schatzki ring retroflexed image.
Endoscopic image of Schatzki ring.
Endoscopic image of Schatzki ring with esophageal varices.
 
 
 
 
 
 
 
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