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Z Gastroenterol 2014; 52(4): 367-373
DOI: 10.1055/s-0034-1366188
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© Georg Thieme Verlag KG Stuttgart · New York

Kritische Betrachtung neuer Konzepte zur endoskopischen Anatomie des ösphagogastralen Übergangs im Sinne des Denkens von Parmenides und Martin Heidegger

Critical Assessment of a New Endoscopic Anatomic Concept for the So-Called Cardia in the Sense of the Notions of Parmenides and Martin Heidegger
M. Riegler
1   Chirurgische Funktionsdiagnostik, Medical University of Vienna
,
R. Asari
2   Department of Surgery, Upper-GI-Service, CCC-GET, Medical University of Vienna
,
E. P. Cosentini
1   Chirurgische Funktionsdiagnostik, Medical University of Vienna
,
F. Wrba
3   Klinisches Institut für Pathologie, Medical University of Vienna
,
S. F. Schoppmann
1   Chirurgische Funktionsdiagnostik, Medical University of Vienna
2   Department of Surgery, Upper-GI-Service, CCC-GET, Medical University of Vienna
› Author Affiliations
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Publication History

22 September 2013

10 February 2014

Publication Date:
09 April 2014 (online)

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Zusammenfassung

Entsprechend der gegenwärtigen endoskopischen Modellanatomie der Speiseröhre und des Magens, beschreibt die Kardia den mit einer Zylinderepithelschleimhaut beschichteten Mageneingang. Neue anatomische Arbeiten stellen diese Vorstellung infrage. Deshalb unternahmen wir eine „PubMed“- und „Scopus“-Recherche zu dem Thema und untersuchten, ob der Weg zur neuen Vorstellung zur Kardia die aus dem Lehrgedicht von Parmenides durch Heidegger dargestellte Entbergung von zuvor Verborgenem nachzeichnet. Was bis dato als Kardia dem Eingang des Magens zugeordnet worden ist, entspricht dem durch unsere Essgewohnheiten und Reflux ausgeleierten, mit Zylinderepithel ausgekleideten Ausgang der Speiseröhre, dem dilaterten distalen Ösophagus (DDÖ). Wegen des gleichen endoskopischen Aussehens kann die Endoskopie nicht zwischen DDÖ und Magen unterscheiden und das distale Ende des Ösophagus nicht erkennen. Dazu bedarf es der Histopathologie von Multi-Level-Biopsien aus dem DDÖ und distal davon. Kardia, oxyntokardia Schleimhaut und intestinale Metaplasie (Barrett-Ösophagus) sind Zylinderepithelösophagus (engl. columnar lined esophagus, CLE) und bestätigen die ösophageale Lokalisation, während oxyntische Mukosa dem Magen angehört. Zusammen mit dem endoskopisch sichtbaren CLE bezeichnet der DDÖ das ösophageale Schleimhautsegment zwischen Plattenepithel und Magenmukosa (engl. squamo-oxyntic gap; SOG). Die Histologie von Biopsien aus der Zwerchfellebene erlaubt die Unterscheidung zwischen einer ausgeweiteten Zwerchfelllücke mit einem der normalen Anatomie entsprechenden Inhalt (= Ösophagus, CLE) oder einer Hernie, welche Magen (OM) enthält. Bei 10 – 17 % jener ohne und 20 – 100 % (je nach Länge) mit endoskopisch sichtbarem CLE findet sich Barrett-Ösophagus (BE) ohne Dysplasie (jährliches Krebsrisiko: 0,2 – 0,7 %). Deshalb empfiehlt sich auch die Biopsie einer sog. endoskopisch normalen Schleimhautgrenze (ora serrata) zum Ausschluss eines BE ± Dysplasie, dessen Therapie sich nach dem Krebsrisiko richtet (Radiofrequenzablation ± endoskopischer Resektion). Die Wahrnehmung der Kardia als refluxgeschädigten Ausgang der Speiseröhre zeichnet die von Heidegger aus dem Lehrgedicht des Parmenides entwickelte Entbergung nach. Es empfiehlt sich den Begriff Kardia fallen zu lassen und stattdessen CLE/DDÖ vs. Magen oder unmögliche Zuordnung (tumorbedingt) zu beschreiben. Zukünftige Studien sollen den Wert des neuen Modells für die Diagnose, Therapie und Krebsprävention untersuchen.

Abstract

Current endoscopic anatomy interposes the gastric cardia between the tubular oesophagus and the proximal stomach. In contrast to that, recent evidence unfolds a different view. Using “PubMed” and “Scopus” searches, we examined if the novel understanding regarding the cardia goes in line with the concept of unfolding, as described by Heidegger based on the ancient didactic poetry of Parmenides. What has been taken as gastric cardia in fact represents reflux-damaged, dilated, columnar lined oesophagus (CLO): dilated distal oesophagus (DDO). Due to its macroscopic gastric appearance it cannot be discriminated from the stomach by endoscopy. Differentiation between DDE and proximal stomach requires the histopathology of measured multi-level biopsies obtained from the DDO and the proximal stomach. Cardaic, onxytocardiac mucosa and intestinal metaplasia (IM; Barrett’s oesophagus) define CLO and thus the oesophageal location, while oxyntic mucosa (OM) of the proximal stomach verifies a gastric biopsy location. Endoscopically visible CLO and DDO define the morphological manifestation of reflux: the squamo-oxyntic gap (SOG). Biopsies obtained from the level of the diaphragmatic impressions allow differentiation between an enlarged hiatus with normal anatomic content (CLO; oesophagus) vs. hernia with abnormal content (OM; stomach). Non-dysplastic Barrett’s oesophagus exists in 10 %–17 % of asymptomatic and in 20 %–100 % (with increasing CLO length) of reflux symptom-positive individuals (annual cancer risk: 0.2 %–0.7 %). These data justify biopsy of an endoscopically normal appearing squamocolumnar junction for the exclusion of Barrett’s oesophagus and cancer risk. In the absence of contraindications, cancer risk-based therapy of dysplastic Barrett’s oesophagus includes radiofrequency ablation (RFA) ± endoscopic resection. The perception of the cardia as reflux damaged DDO mirrors the concept of unfolding, as described by the interpretation of the didactic poem of Parmenides by Heidegger. Our data recommend to omit the term “cardia” and allocate morphology either to the oesophagus (CLO, DDO) or to the proximal stomach or indicate that allocation is impossible (i. e.. tumour-induced). Future studies will have to test the value of this novel concept for diagnosis, treatment of gastro-oesophageal reflux disease and cancer prevention.

Schlüsselwörter

Barrett-Ösophagus - Ösophaguskarzinom - Refluxösophagitis - GERD - Kardia - gastroösophageale Refluxkrankheit - dilatierter distaler Ösophagus - squamo-oxyntic gap - Endoskopie

Key words

Barrett’s oesophagus - oesophageal cancer - reflux oesophagititis - GERD - dilated distal oesophagus - squamo-oxyntic gap - endoscopy - cardia - gastro-esophageal reflux disease
 

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