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Esophagus
The American Journal of Gastroenterology106, 1447-1455 (August
2011)
Epidemiology and Natural History of IntestinalMetaplasia of the
Gastroesophageal Junction and
Barrett's Esophagus: A Population-Based Study
Kee Wook Jung, Nicholas J Talley, Yvonne Romero, David A Katzka,
Cathy D
Schleck, Alan R Zinsmeister, Kelly T Dunagan, Lori S Lutzke,
Tsung-Teh
Wu, Kenneth K Wang, Mary Frederickson, Debra M Geno, G
Richard
Locke andGanapathy A Prasad
OBJECTIVES:
Population-based data on the epidemiology and outcomes of
subjects with
intestinal metaplasia of the gastroesophageal junction (IMGEJ)
and
Barrett's esophagus (BE) are limited. The objectives of this
study were to
(i) estimate the incidence of IMGEJ and BE diagnosed from
clinically
indicated endoscopy in Olmsted County, MN, over three decades
(1976
2006) and prevalence as of 1 January 2007, (ii) compare
baseline
characteristics of subjects with IMGEJ and BE, and (iii) study
the natural
history and survival of both cohorts.
METHODS:
This was a population-based cohort study. The study setting was
Olmsted
County, MN. Patients with BE (columnar segment >1cm with
intestinalmetaplasia) and IMGEJ (intestinal metaplasia in biopsies
from the
gastroesophageal junction) from 1976 to 2006 in Olmsted County,
MN,
were identified using Rochester Epidemiology Project
resources.
Demographic and clinical data were abstracted from medical
records andpathology confirmed by gastrointestinal pathologists.
The association of
baseline characteristics with overall and progression-free
survival was
assessed using proportional hazards regression models.
Outcome
measures were baseline characteristics and overall survival of
subjects
with IMGEJ compared to those with BE.
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RESULTS:
In all, 487 patients (401 with BE and 86 with IMGEJ) were
identified and
followed for a median interval of 7 (BE subjects) to 8 (IMGEJ
subjects)
years. Subjects with BE were older, heavier, reported reflux
symptomsmore often, and had higher prevalence of advanced neoplasia
than those
with IMGEJ. No patient with IMGEJ progressed to esophageal
adenocarcinoma (EAC) in contrast to BE subjects who had a
cumulative
risk of progression of 7% at 10 years and increased risk of
death from EAC
(standardized mortality ratio 9.62). The overall survival of
subjects with
BE and IMGEJ did not differ from that expected in similar age-
and sex-
distributed white Minnesota populations.
CONCLUSIONS:
Subjects with IMGEJ appear to have distinct clinical
characteristics and
substantially lower cancer progression risk compared to those
with BE.
Response of Regurgitation to Proton PumpInhibitor Therapy in
Clinical Trials of
Gastroesophageal Reflux Disease
Peter J Kahrilas, Colin W Howden and Nesta Hughes
Abstract
OBJECTIVES:
The typical symptoms of gastroesophageal reflux disease (GERD)
are
heartburn and regurgitation. Extensive analysis has
characterized
heartburn and its responsiveness to proton pump inhibitor (PPI)
therapy,
but regurgitation has received relatively little attention. This
study aimed
to evaluate the response of regurgitation to PPI therapy in GERD
trials.
METHODS:
Studies were identified by systematic searches in PubMed and
Embase, as
well as searching congress abstracts and the reference lists of
Cochrane
reviews.
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RESULTS:
Regurgitation was not an entry criterion or the primary end
point in any of
the 31 clinical trials reporting the response of regurgitation
to PPI
treatment in GERD. The definitions of regurgitation and
responsivenessvaried among trials and over half used investigator
assessment of
response. Owing to these inconsistencies, no meta-analysis
was
attempted. In seven placebo-controlled trials of PPI therapy,
the
therapeutic gain for regurgitation response averaged 17%
relative to
placebo and was >20% less than that observed for heartburn.
Studies
comparing PPIs with histamine-2 receptor antagonists or
prokinetics found
the comparator drug response similar to the placebo response
rates seen
in the placebo-controlled trials.
CONCLUSIONS:
The therapeutic gain with PPIs over placebo or comparator agents
for the
relief of regurgitation is modest, and considerably lower than
for
heartburn. Thus, regurgitation is likely to be an important
factor for
determining incomplete response to PPI treatment in GERD. Future
trials
would benefit from using regurgitation as a primary end point,
applying an
unambiguous definition of the symptom and of a positive
treatment
response, and using a validated patient-reported instrument
for
regurgitation assessment.
