The gastroesophageal junction (GEJ) is an ill-defined, physiologically and pathologically
highly active transition zone connecting the esophagus to the stomach [1 ]
[2 ]. Although several endoscopic and histologic aspects such as the Z-line, cardia,
tongues, and/or tiny islands of cylindrical epithelial cells have been well described
[2 ]
[3 ], we have often observed the presence of small yellow vesicles or cysts above the
Z-line in some patients. These lesions have not been described in the literature.
During upper endoscopy of consecutive patients undergoing the procedure for reflux
symptoms or dyspepsia, all potential physiologic and pathologic lesions found in the
esophagus and stomach were carefully examined and described (e. g. inlet patches,
glycogenic acanthosis, cylindrical epithelia, gastritis, atrophy, metaplasia). The
occurrence of these yellow vesicles was analyzed in the context of these lesions (univariate
and multivariate analysis, Mann–Whitney, and Student’s t test). In a total of 197 patients (102 women and 95 men; mean age 55.5 [SD 15] years),
the incidence of yellow vesicles was 30 % ([Fig. 1 ], [Fig. 2 ], [Video 1 ]). Some lesions had a “volcano-like” shape, with cylindrical epithelium on its tip. Their
sizes ranged from 2 mm to 10 mm. These yellow vesicles had a significant correlation
with columnar-lined epithelium (including Barrett’s esophagus) (P = 0.009) and an inverse correlation with erosive esophagitis (P = 0.024) and female sex (P = 0.011).
Fig. 1 Spectrum of esophageal outlet vesicles or cysts. a The lesions were visualized using standard and high definition white-light endoscopes.
b Narrow-band imaging. c Magnification up to × 110 (Q160Z; Olympus, Hamburg, Germany). Note the characteristic
cyst-like structures. d, e Some lesions had a “volcano-like” appearance. f The lesions were often located close to tongues of cylindrical epithelium. g All lesions were located above the Z-line, on the squamous epithelium.
Fig. 2 Histologic (hematoxylin and eosin) and electron microscopic characterization. a Histology demonstrated submucosal glands (28 %), cylindrical epithelium (including
intestinal metaplasia) (25 %), gastric heterotopia (15 %), squamous epithelium or
inflammation (30 %), and pancreatic metaplasia (5 %). b Often the lesions were considered to be “ectopic gastric mucosa” or esophageal “inlet
patches.” c In 10 patients, we also performed electron microscopy with magnification up to × 7000
(Philips, Eindhoven, the Netherlands). d Some cells of the cystic lesions had features combining those of squamous and columnar
epithelium. The surface of many submucosal cells showed microvilli (feature of glandular
epithelium) and intercellular ridges (feature of squamous epithelium).
Video 1 Endoscopic, histologic, and electron microscopic views of novel small vesicles with
gastric heterotopia, intestinal metaplasia, and/or submucosal glands at the gastroesophageal
junction.
In summary, yellow vesicles are definable lesions in the distal esophagus, above the
GEJ, and are found in 30 % of patients undergoing esophagogastroduodenoscopy for clinical
symptoms. These lesions are located on the squamous mucosa but contain submucosal
glands, cylindrical epithelium, and/or gastric or pancreatic 4metaplasia. Yellow vesicles
are associated with columnar-lined epithelium (Barrett’s esophagus) and inversely
associated with female sex and less erosive esophagitis, suggesting a protective mechanism
of the GEJ. We propose the term esophageal “outlet or GEJ cysts.”
Endoscopy_UCTN_Code_CCL_1AB_2AC_3AH
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