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Z Gastroenterol 2001; 39(8): 593-600
DOI: 10.1055/s-2001-16695
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© Karl Demeter Verlag im Georg Thieme Verlag Stuttgart · New York

Überwachung von Patienten mit Barrett-Ösophagus - eine Übersicht

Surveillance of patients with Barrett’s esophagusE. Endlicher2 , R. Knüchel1 , H. Messmann2
  • Klinik und Poliklinik für Innere Medizin I
  • , Institut für Pathologie, Universität Regensburg
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Publication History

18.01.2000

5.01.2001

Publication Date:
27 August 2001 (online)

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Zusammenfassung

Der Barrett-Ösophagus stellt eine schwer wiegende Komplikation des gastroösophagealen Refluxes dar und ist mit einem 30- bis 125fach erhöhten Karzinomrisiko assoziiert. Dabei hat die Zunahme der Inzidenz des Adenokarzinoms den Barrett-Ösophagus in den Blickpunkt des Interesses gestellt. Nach anfänglichen Unstimmigkeiten in der Definition des Barrett-Ösophagus werden heute Barrett-Segmente, d. h. histologischer Nachweis von spezialisiertem intestinalisierten Zylinderepithel, von mehr als 3 cm Länge allgemein als Long-Segment-Barrett-Ösophagus (LBS) und solche mit weniger als 3 cm Ausdehnung als Short-Segment-Barrett-Ösophagus (SBS) bezeichnet. Histologischer Nachweis von intestinalem Epithel ohne entsprechende endoskopische Veränderungen wird als mikroskopischer Barrett- oder Ultra-Short-Barrett-Ösophagus definiert.

Der Nachweis dysplastischer Veränderungen gilt als der wichtigste Risikofaktor für die Entstehung eines Adenokarzinoms. Die Überwachungsempfehlungen orientieren sich am Vorhandensein bzw. Fehlen von Dysplasien unterschiedlichen Schweregrades. Zahlreiche neue Methoden (Färbeverfahren, Fluoreszenzdiagnostik, optische Kohärenztomographie) werden in der Diagnostik des Barrett-Ösophagus und der Früherkennung maligner und prämaligner Läsionen evaluiert. Dennoch sind zum jetzigen Zeitpunkt 4 Quadrantenbiopsien in Abständen von 1-2 cm für den LBS empfehlenswert, die Zeitintervalle werden dabei vom Nachweis dysplastischer Areale bestimmt. Ob Patienten mit SBS ähnlich wie Patienten mit LBS zu überwachen sind, ist noch unklar und bedarf weiterer Studien.

Surveillance of patients with Barrett’s esophagus

Barrett’s esophagus is a major complication of gastroesophageal reflux disease and is associated with 30-125 fold increased risk of developing carcinoma. Because of the rising incidence of esophageal adenocarcinoma the malignant potential of Barrett’s esophagus has been generally recognized. The definition of Barrett’s esophagus has evolved over the last decades. It is now accepted that “Long-Barrett-Segment” (LBS) is used when intestinal-type epithelium, characterized by the presence of goblet cells, is detected in the distal esophagus > 3 cm in length. The term “Short-Barrett-Segment” (SBS) is defined by intestinal metaplasia detection < 3 cm in length in the distal esophagus. Recently, there has been focus on microscopic Barrett’s esophagus, so called “Ultra-Short-Barrett’s esophagus”, with histological evidence of intestinal metaplasia without endoscopic appearance.

The most significant predictor of the risk of malignancy in patients with Barrett’s esophagus is the presence of dysplasia. Guidelines for surveillance are based on the diagnosis of dysplastic lesions. New methods (e. g. Methylene blue staining, endoscopic fluorescence detection, OCT) to improve the recognition of Barrett’s esophagus and especially enhance the detection of premaligant and malignant lesions are under evaluation. So far, the standard biopsy protocol for patients with LBS includes biopsies in the 4 quadrants every 1-2 cm, whereas the appropriate surveillance intervals are dependent on the grade of dysplasia. Whether surveillance in patients with SBS has to be similar to that in patients with LBS is unclear and needs further evaluation.

Schlüsselwörter

Barrett-Ösophagus - Überwachung - 5-Aminolävulinsäure - endoskopische Fluoreszenzdiagnostik - Dysplasie - Adenokarzinom - Färbeverfahren

Key words

Barrett’s Esophagus - Surveillance - 5-aminolevulinic Acid - Endoscopic Fluorescence Detection - Dysplasia - Adenocarcinoma - Methylene Blue Staining

Literatur

  • 1 Adrian A, Ter H, Cassidy M. et al . High-resolution endoluminal sonography is a sensitive modality for the identification of Barrett’s esophagus.  Gastrointest Endosc. 1997;  46 147-151
    Google Scholar
  • 2 Brand S, Ponero J, Bouma B. et al . Optical coherence tomography in the gastrointestinal tract.  Endoscopy. 2000;  32 796-803
    Google Scholar
  • 3 Bytzer P, Christensen P, Damkier P, Vinding K, Seersholm N. Adenocarcinoma of the esophagus and Barrett’s esophagus: A population-based study.  Am J Gastroenterol. 1999;  94 86-91
    Google Scholar
  • 4 Cameron A, Carpenter H. Barrett’s esophagus, high-grade dysplasia and early adenocarcinoma.  Am J Gastroenterol. 1997;  92 586-591
    Google Scholar
  • 5 Cameron A, Ott B, Payne W. The incidence of adenocarcinoma in columnar-lined (Barrett’s) esophagus.  N Engl J Med. 1985;  313 857-859
    Google Scholar
  • 6 Canto M, Setrakian S, Willis J. et al . Methylene blue-directed biopsies improve detection of intestinal metaplasia and dysplasia in Barrett’s esophagus.  Gastrointest Endosc. 2000;  51 560-568
    Google Scholar
  • 7 Caygill C, Reed P, Johnston B. et al . A Single center’s 20 years’ experience of columnar-lined (Barrett’s) esophagus diagnosis.  Eur J Gastroenterol Hepatol. 1999;  11 1355-1358
    Google Scholar
  • 8 Clark G, Ireland A, Peters J. et al . Short-segment Barrett’s esophagus: A prevalent complication of gastroesophageal reflux disease with malignant potential.  J Gastrointest Surg. 1997;  1 113-122
    Google Scholar
  • 9 DeMas C, Krämer M, Seifert E, Vieth M, Stolte M. Short Barrett: prevalence and risk factors.  Scand J Gastroenterol. 1999;  11 1065-1070
    Google Scholar
  • 10 Drewitz D, Sampliner R, Garewal H. The incidence of adenocarcinoma in Barrett’s esophagus: A prospective study of 170 patients followed 4.8 years.  Am J Gastroenterol. 1997;  92 212-215
    Google Scholar
  • 11 Ell C, May A, Gossner L. et al . Endoscopic mucosal resection of early cancer and high-grade dysplasia in Barrett’s esophagus.  Gastroenterology. 2000;  118 670-677
    Google Scholar
  • 12 Endlicher E, Knüchel R, Hauser T. et al . Endoscopic fluorescence detection of low and high grade dysplasia in Barrett’s oesophagus using systemic or local 5-aminolevulinic acid sensitization.  Gut. 2001;  48 314-319
    Google Scholar
  • 13 Falk G. Barrett’s esophagus.  Gastrointest Endosc Clin N Am. 1994;  4 773-789
    Google Scholar
  • 14 Falk G, Catalano M, Sivak M, Rice T, Dam J V. Endosonography in the evaluation of patients with Barrett’s esophagus and high grade dysplasia.  Gastrointest Endosc. 1994;  40 207-212
    Google Scholar
  • 15 Falk G, Ours T, Richter J. Practice pattern for surveillance of Barrett’s esophagus in the United States.  Gastrointest Endosc. 2000;  52 197-203
    Google Scholar
  • 16 Falk G, Rice T, Goldblum J, Richter J. Jumbo biopsy forceps protocol still misses unsuspected cancer in Barrett’s esophagus with high-grade dysplasia.  Gastrointest Endosc. 1999;  49 170-176
    Google Scholar
  • 17 Gangarossa L, Halter S, Mertz H. Methylene blue staining and endoscopic ultrasound evaluation of Barrett’s esophagus with low-grade dysplasia.  Dig Dis Sci. 2000;  45 225-229
    Google Scholar
  • 18 Gleeson C, McDougall N, Russell S. et al . Microsatellite analysis provides evidence of neoplastic transformation in long-segment, but not in short-segment, Barrett’s oesophagus.  Int J Cancer. 2000;  85 482-485
    Google Scholar
  • 19 Gossner L, Stolte M, Sroka R. et al . Photodynamic ablation of high-grade dysplasia and early cancer in Barrett’ s esophagus by means of 5-aminolevulinic acid.  Gastroenterology. 1998;  114 448-455
    Google Scholar
  • 20 Gross C, Canto M, Hixson J, Powe N. Management of Barrett’s esophagus: A national study of practice patterns and their cost implications.  Am J Gastroenterol. 1999;  94 3440-3447
    Google Scholar
  • 21 Grunewald M, Vieth M, Kreibich H, Bethke B, Stolte M. Untersuchungen zum Stand der Diagnostik des Barrett-Ösophagus.  Dtsch Med Wochenschr. 1997;  122 427-431
    Google Scholar
  • 22 Hameeteman W, Tytgat G, Houthoff H, van den Tweel J. Barrett’s esophagus: Development of dysplasia and adenocarcinoma.  Gastroenterology. 1989;  96 1249-1256
    Google Scholar
  • 23 Haringsma J, Prawirodirdjo W, Tytgat G. Accuracy of fluorescence imaging of dysplasia in Barrett’s esophagus.  Gastroenterology. 1999;  116 A418
    Google Scholar
  • 24 Iftikhar S, James P, Steele R, Hardcastle J, Atkinson M. Length of Barrett’s esophagus: An important factor in the development of dysplasia and adenocarcinoma.  Gut. 1992;  33 1155-1158
    Google Scholar
  • 25 Jäckle S, Gladkova N, Feldchtein F. et al . In vivo optical coherence tomography of the human gastrointestinal tract-toward optical biopsy.  Endoscopy. 2000;  32 743-749
    Google Scholar
  • 26 Klump B, Hsieh C, Holzmann K. et al . Diagnostic significance of nuclear p53 expression in the surveillance of Barrett’s esophagus - a longitudinal study.  Z Gastroenterol. 1999;  37 1005-1011
    Google Scholar
  • 27 Lagergren J, Bergström R, Lindgren A, Nyren O. Symptomatic gastroesophageal reflux as a risk factor for esophageal adenocarcinoma.  N Engl J Med. 1999;  340 825-831
    Google Scholar
  • 28 Levine D, Blount P, Rudolph R, Reid B. Saftey of a systematic endoscopic biopsy protocol in patients with Barrett’s esophagus.  Am J Gastroenterol. 2000;  95 1152-1157
    Google Scholar
  • 29 Levine D, Haggitt R, Blount P. et al . An endoscopic biopsy protocol can differentiate high-grade dysplasia from early adenocarcinoma in Barrett’s esophagus.  Gastroenterology. 1993;  105 40-50
    Google Scholar
  • 30 Mann N, Tsai M, Nair P. Barrett’s esophagus in patients with symptomatic reflux esophagitis.  Am J Gastroenterol. 1989;  84 1494-1496
    Google Scholar
  • 31 Marshall R, Anggiansah A, Owen W. Bile in the oesophagus: Clinical relevance and ambulatory detection.  Br J Surg. 1997;  84 21-28
    Google Scholar
  • 32 Messmann H, Knüchel R, Szeimies R. et al . Endoscopic fluorescence detection of dysplasia in patients with Barrett’s oesophagus, ulcerative colitis or adenomatous polyps after 5-amino- laevulinic induced protoporphyrin IX sensitization.  Gastrointest Endosc. 1999;  49 97-101
    Google Scholar
  • 33 Miros M, Kerlin P, Walker N. Only patients with dysplasia progress to adenocarcinoma in Barrett’s esophagus.  Gut. 1991;  32 1441-1446
    Google Scholar
  • 34 Nishimaki T, Hölscher A, Schüler M. et al . Histopathologic characteristics of early adenocarcinoma in Barrett’s esophagus.  Cancer. 1991;  68 1731-1736
    Google Scholar
  • 35 O’Connor J, Falk G, Richter J. The incidence of adenocarcinoma and dysplasia in Barrett’s esophagus: Report on the Cleveland Clinic Barrett’s Esophagus Registry.  Am J Gastroenterol. 1999;  94 2037-2042
    Google Scholar
  • 36 Ormsby A, Vaezi M, Richter J. et al . Cytokeratin immunoreactivity patterns in the diagnosis of short-segment Barrett’s esophagus.  Am J Gastroenterol. 2000;  119 683-690
    Google Scholar
  • 37 Overholt B, Panjehpour M, Haydek J. Photodynamic therapy for Barrett’s esophagus: Follow-up in 100 patients.  Gastrointest Endosc. 1999;  49 1-7
    Google Scholar
  • 38 Pally S, Sampliner R, Garewal H. Management of high-grade dysplasia in Barrett’s esophagus.  J Clin Gastroenenterol. 1989;  11 369-372
    Google Scholar
  • 39 Panjehpour M, Overholt B, Vo-Dinh T. et al . Endoscopic fluorescence detection of high-grade dysplasia in Barrett’s esophagus.  Gastroenterology. 1996;  111 93-101
    Google Scholar
  • 40 Provenzale D, Schmitt C, Wong J. Barrett’s esophagus: A new look at surveillance based on emerging estimates of cancer risk.  Am J Gastroenterol. 1999;  94 2043-2053
    Google Scholar
  • 41 Reid B, Blount P, Rubin C. et al . Flow-cytometric and histological progression to malignancy in Barrett’s esophagus: Prospective endoscopic surveillance of a cohort.  Gastroenterology. 1992;  102 1212-1219
    Google Scholar
  • 42 Reid B, Haggitt R, Rubin C. et al . Observer variation in the diagnosis of dysplasia in Barrett’s esophagus.  Hum Pathol. 1988;  19 166-178
    Google Scholar
  • 43 Reid B, Levine D, Longton G, Blount P, Rabinovitch P. Predictors of progression to cancer in Barrett’s esophagus: Baseline histology and flow cytometry identify low- and high-risk patient subset.  Am J Gastroenterol. 2000;  95 1669-1676
    Google Scholar
  • 44 Robertson C, Mayberry I, Nicholson D, James P, Atkinson M. Value of endoscopic surveillance in the detection of neoplastic change in Barrett’s oesophagus.  Br J Surg. 1988;  75 760-763
    Google Scholar
  • 45 Sampliner R. Practice guidelines on the diagnosis, surveillance and therapy of Barrett’s esophagus. The Practice Parameters Committee of the American College of Gastroenterology.  Am J Gastroenterol. 1998;  93 1028-1032
    Google Scholar
  • 46 Shaheen N, Crosby M, Bozymski E, Sandler R. Is there a publication bias in the reporting of cancer risk in Barrett’s esophagus?.  Gastroenterology. 2000;  119 333-338
    Google Scholar
  • 47 Sharma P, Morales T, Bhattacharyya A, Garewal H, Sampliner R. Dysplasia in short-segment Barrett’s esophagus: A prospective 3-year follow-up.  Am J Gastroenterol. 1997;  92 2012-2016
    Google Scholar
  • 48 Sharma P, Weston A, Morales T. et al . Relative risk of dysplasia for patients with intestinal metaplasia in the distal oesophagus and in the gastric cardia.  Gut. 2000;  46 9-13
    Google Scholar
  • 49 Sjögren R, Johnson L. Barrett’s esophagus: A review.  Am J Med. 1983;  74 313-321
    Google Scholar
  • 50 Soni A, Sampliner R, Sonnenberg A. Screening for high-grade dysplasia in gastroesophageal reflux disease: Is it cost effective?.  Am J Gastroenterol. 2000;  95 2086-2093
    Google Scholar
  • 51 Spechler S, Robbins A, Rubins H. Adenocarinoma and Barrett’s esophagus: An overrated risk?.  Gastroenterology. 1984;  87 927-933
    Google Scholar
  • 52 Srivastava A, Vanagunas A, Kamel P, Cooper R. Endoscopic ultrasound in the evaluation of Barrett’s esophagus: A preliminary report.  Am J Gastroenterol. 1994;  89 2192-2195
    Google Scholar
  • 53 von Stael H olstein C, Nilsson A, Andersson-Engels S. et al . Detection of adenocarcinoma in Barrett’s esophagus by means of laser-induced fluorescence.  Gut. 1996;  39 711-716
    Google Scholar
  • 54 Stein H, Kauer W, Feussner H, Siewert J. Bile reflux in benign and malignant Barrett’s esophagus: Effect of medical acid suppression and Nissen fundoplicatio.  J Gastrointest Surg. 1998;  2 333-341
    Google Scholar
  • 55 Streitz J, Andrews C, Ellis F. Endoscopic surveillance of Barrett’s esophagus.  J Thorac Cardiovasc Surg. 1993;  105 383-388
    Google Scholar
  • 56 Streitz J, Ellis F, Tilden R, Erickson R. Endoscopic surveillance of Barrett’s esophagus: A cost-effectivness comparison with mammographic surveillance for breast cancer.  Am J Gastroenterol. 1998;  93 911-915
    Google Scholar
  • 57 Vaezi M, Falk G, Peek R. et al . CagA-positive strains of Helicobacter pylori may protect against Barrett’s esophagus.  Am J Gastroenterol. 2000;  95 2206-2211
    Google Scholar
  • 58 Vaezi M, Richter J. Bile reflux in columnar-lined esophagus.  Gastroenterol Clin North Am. 1997;  26 565-582
    Google Scholar
  • 59 Van Sandick J, Bartelsman J, van Lanschot J, Tytgat G, Obertop H. Surveillance of Barrett’s esophagus: Physicians’ practices and review of current guidelines.  Eur J Gastroenterol Hepatol. 2000;  12 111-117
    Google Scholar
  • 60 Van Sandick J, van Lanschot J, Kuiken B. et al . Impact of endoscopic biopsy surveillance of Barrett’s esophagus on pathological stage and clinical outcome of Barrett’s carcinoma.  Gut. 1998;  43 216-222
    Google Scholar
  • 61 Vieth M, Stolte M. Barrett’s mucosa, Barrett’s dysplasia and Barrett’s carcinoma: Diagnostic endoscopy without biopsy- taking does not suffice.  Dis Esoph. 2000;  13 23-27
    Google Scholar
  • 62 Wallace M, Perelman L, Backman V. et al . Endoscopic detection of dysplasia in patients with Barrett’s esophagus using light scattering spectroscopy.  Gastroenterology. 2000;  119 677-682
    Google Scholar
  • 63 Weston A, Badr A, Hassanein R. Prospective multivariate analysis of clinical, endoscopic, and histological factors predictive of the development of Barrett’s multifocal high-grade dysplasia or adenocarcinoma.  Am J Gastroenterol. 1999;  94 3413-3419
    Google Scholar
  • 64 Weston A, Badr A, Topalovski M. et al . Prospective evaluation of the prevalence of gastric Helicobacter pylori infection in patients with GERD, Barrett’s esophagus, Barrett’s dysplasia, and Barrett’s adenocarcinoma.  Am J Gastroenterol. 2000;  95 387-394
    Google Scholar
  • 65 Weston A, Krmpotich P, Cherian R, Dixon A, Topalosvki M. Prospective long-term endoscopic and histological follow-up of short segment Barrett’s esophagus: Comparison with traditional long segment Barrett’s esophagus.  Am J Gastroenterol. 1997;  92 407-413
    Google Scholar
  • 66 Weston A, Sharma P, Topalovski M. et al . Long-term follow-up of Barrett’s high-grade dysplasia.  Am J Gastroenterol. 2000;  95 1888-1893
    Google Scholar
  • 67 Winters C J, Spurling T, Chobanian S. et al . Barrett’s esophagus: A prevalent occult complication of gastroesophageal reflux disease.  Gastroenterology. 1987;  92 118-124
    Google Scholar
  • 68 Wright T. High-grade dysplasia in Barrett’s esophagus.  Br J Surg. 1997;  84 760-766
    Google Scholar

PD Dr. H. Messmann

Klinik und Poliklinik für Innere Medizin I
Klinikum der Universität Regensburg

93042 Regensburg

Email: helmut.messmann@klinik.uni-regensburg.de

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