Symptomatic Ulceration of an Acid-Producing Oesophageal Inlet Patch Colonized by Helicobacter Pylori

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Heterotopic gastric mucosa in the upper oesophagus is also known as an inlet patch and has a prevalence at endoscopy estimated at 2 - 4 % [1]. These lesions are usually asymptomatic and clinically unimportant [2] [3], but are occasionally symptomatic with dysphagia or heartburn or they may rarely ulcerate, perforate or bleed [4] [5]. In this report, we describe symptomatic ulceration in an inlet patch in the cervical oesophagus of a 33-year-old man, who had a 6-month history of right-sided neck swelling, heartburn, mild dysphagia when swallowing saliva, and a sore throat. Gastroscopy showed normal stomach, duodenal cap and lower oesophagus, but on withdrawal of the endoscope two areas of “salmon”-coloured mucosa in the upper oesophagus were seen, in a “kissing” distribution on the lateral walls of the oesophagus, 20 cm from the lips. Within one patch there was an ulcer (Figure [1]). There was no history of pill ingestion. Histological examination showed gastric-type glandular mucosa (parietal cells present) with acute and chronic inflammation and ulceration.

Figure 1 Inlet patch in cervical oesophagus with a patch of “salmon”-coloured mucosa containing an ulcer

The patient was prescribed lansoprazole (30 mg twice daily) for 2 months. As Helicobacter-like organisms were seen in the tissue and the role of H. pylori in these lesions is unknown, he was also given H. pylori eradication treatment. At 9 weeks later he was symptomatically much improved and had a repeat endoscopy showing the gastric inlet patch but no ulcer. Congo red dye (1 % in distilled water) was applied to the patch. After 5 minutes, small punctate areas within the patch turned from red to black, confirming a fall in pH and that this patch was acid-producing (Figure [2]). He remained asymptomatic at 6 months after initial presentation, taking lansoprazole 30 mg daily. This case highlights the need to carefully examine the cervical oesophagus in patients with dysphagia localized to the upper oesophagus or with cricopharyngeal spasm.

Figure 2 Demonstration of acid-producing nature of the inlet patch using Congo red. Several black punctate areas confirm a fall in pH

References

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