Methylene Blue Chromoendoscopy for the Detection of Barrett’s Esophagus in a Greek Cohort

Introduction

Barrett’s esophagus is a premalignant condition defined as replacement of the normal distal esophageal epithelium by specialized columnar epithelium, characterized by the presence of goblet cells; it is also known as specialized intestinal metaplasia [1]. Affecting predominantly male white individuals, this disorder is found in 8-20 % of patients undergoing endoscopy for symptoms of gastroesophageal reflux [2]. It is associated with an increased risk of esophageal adenocarcinoma, with an estimated annual incidence of 0.5 % [3].

The classic definition of Barrett’s esophagus requires the presence of more than 3 cm of metaplastic epithelium proximal to the esophagogastric junction [4]. However, short segments of Barrett’s epithelium, less than 3 cm in length, are being reported with increasing frequency and have been implicated as a risk factor in the development of adenocarcinoma of the distal esophagus [5] [6] [7] [8]. Endoscopic diagnosis of this entity is difficult and always requires a histological demonstration of specialized columnar epithelium. Most endoscopists do not obtain biopsies unless the Barrett’s mucosa presents a specific salmon-pink appearance, so these short segments frequently go unrecognized. In addition, some authors have recently described the presence of intestinal metaplasia in normal-appearing esophagogastric junctions [7] [9]. The diagnosis of Barrett’s esophagus is therefore currently based on the histological finding of specialized intestinal metaplasia in any biopsy, regardless of the endoscopic appearance of the esophagus [7] [10].

Methylene blue is a dye that is taken up by metaplastic absorptive epithelium, such as intestinal-type metaplastic tissue in the stomach and esophagus [10] [11] [12] [13]. In contrast, it does not stain nonabsorptive epithelium, such as squamous or gastric mucosa [12]. Methylene blue appears to be highly accurate in the selective staining of specialized columnar epithelium of Barrett’s esophagus, and it has been recently suggested that methylene blue-directed biopsies could be used to improve endoscopic surveillance in patients with Barrett’s esophagus [14].

The aim of the present study was to assess the detection of suspected short-segment and long-segment Barrett’s esophagus in a large cohort of patients in Greece undergoing diagnostic upper gastrointestinal endoscopy, mainly due to gastroesophageal reflux disease (GERD) and/or dyspeptic symptoms. Methylene blue chromoendoscopy-directed biopsies were compared with biopsies obtained using conventional endoscopic criteria.

References

• 1 Hirota W K, Loughney T M, Lazas D J. et al . Specialized intestinal metaplasia, dysplasia, and cancer of the esophagus and esophagogastric junction: prevalence and clinical data.  Gastroenterology. 1999;  116 277-285
• 2 Spechler S J, Goyal R K. Barrett’s esophagus.  N Engl J Med. 1986;  315 362-371
• 3 DeVault K R. Epidemiology and significance of Barrett’s esophagus.  Dig Dis. 2000;  18 195-202
• 4 Clark G WB, Smyrk T C, Burdeles P. et al . Is Barrett’s metaplasia the source of adenocarcinoma of the cardia?.  Arch Surg. 1994;  129 609-614
• 5 Cameron A J, Lomboy C T, Pera M. et al . Adenocarcinoma of the esophagogastric junction and Barrett’s esophagus.  Gastroenterology. 1995;  109 1541-1546
• 6 Oberg S, Clark G WB, DeMeester T R. Barrett’s esophagus: update of pathophysiology and management.  Hepatogastroenterology. 1998;  45 1348-1356
• 7 Nandurkar S, Talley N J. Barrett’s esophagus: The long and the short of it.  Am J Gastroenterol. 1999;  94 30-40
• 8 Spechler S J, Zeroogian J M, Antonioli D A. et al . Prevalence of metaplasia at the gastroesophageal junction.  Lancet. 1994;  344 1533-1536
• 9 Kountouras J, Boura P, Lygidakis N J. New concepts of molecular biology for colon carcinogenesis.  Hepatogastroenterology. 2000;  47 1291-1297
• 10 Ida K, Hashimoto Y, Kawai K. In vivo staining of gastric mucosa: its application to endoscopic diagnosis of intestinal metaplasia.  Endoscopy. 1975;  7 18-24
• 11 Fennerty M B, Sampliner R E, McGee D L. et al . Intestinal metaplasia in the stomach: identification by a selective mucosal staining technique.  Gastrointest Endosc. 1992;  38 696-698
• 12 Canto M I. Vital staining and Barrett’s esophagus.  Gastrointest Endosc. 1999;  49 S12-S16
• 13 Canto M I, Setrakian S, Willis J. et al . Methylene blue-directed biopsy for improved detection of intestinal metaplasia and dysplasia in Barrett’s esophagus: a controlled sequential trial [abstract].  Gastrointest Endosc. 1996;  43 165
• 14 Sampliner R E. Practice Parameters Committee of the American College of Gastroenterology. Practice guidelines on the diagnosis, surveillance and therapy of Barrett’s esophagus.  Am J Gastroenterol. 1998;  93 1028-1032
• 15 Gruppo Operativo per lo Studio delle Precancerosi dell’Esofago (GOSPE). Barrett’s esophagus: epidemiological and clinical results of a multicentric survey.  Int J Cancer. 1991;  48 364-368
• 16 Kim S, Waring P, Spechler S. et al . Diagnostic inconsistencies in Barrett’s esophagus.  Gastroenterology. 1994;  107 945-949
• 17 Woolf G, Riddell R, Irvine E, Hunt R. A study to examine agreement between endoscopy and histology for the diagnosis of columnar-lined (Barrett’s) esophagus.  Gastrointest Endosc. 1989;  35 541-544
• 18 Stevens P, Lightdale C, Green P. et al . Combined magnification endoscopy with chromoendoscopy for the evaluation of Barrett’s esophagus.  Gastrointest Endosc. 1994;  40 747-749
• 19 Canto M IF, Setrakian S, Petras R E. et al . Methylene blue selectively stains intestinal metaplasia in Barrett’s esophagus.  Gastrointest Endosc. 1996;  44 1-7
• 20 Morales T G, Bhattacharyya A, Camargo E. et al . Methylene blue staining for intestinal metaplasia of the gastric cardia with follow-up for dysplasia.  Gastrointest Endosc. 1998;  48 26-31
• 21 Kiesslich R, Hahn M, Hermann G, Jung M. Screening for specialized columnar epithelium with methylene blue: chromoendoscopy in patients with Barrett’s esophagus and a normal control group.  Gastrointest Endosc. 2001;  53 47-52
• 22 Sharma P, Topalovski M, Mayo M S, Weston A P. Methylene blue chromoendoscopy for detection of short-segment Barrett’s esophagus.  Gastrointest Endosc. 2001;  54 289-293