Prevalence of Barrett’s Esophagus in the General Population: An Endoscopic Study
2005; Elsevier BV; Volume: 129; Issue: 6 Linguagem: Inglês
10.1053/j.gastro.2005.08.053
ISSN1528-0012
AutoresJukka Ronkainen, Pertti Aro, Tom Storskrubb, Sven‐Erik Johansson, Tore Lind, E. Bolling‐Sternevald, Michael Vieth, Manfred Stolte, Nicholas J. Talley, Lars Agréus,
Tópico(s)Gastroesophageal reflux and treatments
ResumoBackground & Aims: Barrett’s esophagus (BE) is associated with esophageal adenocarcinoma, the incidence of which has been increasing dramatically. The prevalence of BE in the general population is uncertain because upper endoscopy is required for diagnosis. This study aimed to determine the prevalence of BE and possible associated risk factors in an adult Swedish population. Methods: A random sample (n = 3000) of the adult population (n = 21,610) in 2 municipalities was surveyed using a validated gastrointestinal symptom questionnaire (response rate, 74%); a random subsample (n = 1000; mean age, 53.5 years; 51% female) underwent upper endoscopy. Endoscopic signs suggestive of columnar-lined esophagus (CLE) were defined as mucosal tongues or an upward shift of the squamocolumnar junction. BE was diagnosed when specialized intestinal metaplasia was detected histologically in suspected CLE. Results: BE was present in 16 subjects (1.6%; 95% confidence interval, 0.8–2.4): 5 with a long segment and 11 with a short segment. Overall, 40% reported reflux symptoms and 15.5% showed esophagitis; 103 (10%) had suspected CLE, and 12 (1.2%) had a visible segment ≥2 cm. The prevalence of BE in those with reflux symptoms was 2.3% and in those without reflux symptoms was 1.2% (P = .18). In those with esophagitis, the prevalence was 2.6%; in those without, the prevalence was 1.4% (P = .32). Alcohol (P = .04) and smoking (P = .047) were independent risk factors for BE. Conclusions: BE was found in 1.6% of the general Swedish population. Alcohol and smoking were significant risk factors. Background & Aims: Barrett’s esophagus (BE) is associated with esophageal adenocarcinoma, the incidence of which has been increasing dramatically. The prevalence of BE in the general population is uncertain because upper endoscopy is required for diagnosis. This study aimed to determine the prevalence of BE and possible associated risk factors in an adult Swedish population. Methods: A random sample (n = 3000) of the adult population (n = 21,610) in 2 municipalities was surveyed using a validated gastrointestinal symptom questionnaire (response rate, 74%); a random subsample (n = 1000; mean age, 53.5 years; 51% female) underwent upper endoscopy. Endoscopic signs suggestive of columnar-lined esophagus (CLE) were defined as mucosal tongues or an upward shift of the squamocolumnar junction. BE was diagnosed when specialized intestinal metaplasia was detected histologically in suspected CLE. Results: BE was present in 16 subjects (1.6%; 95% confidence interval, 0.8–2.4): 5 with a long segment and 11 with a short segment. Overall, 40% reported reflux symptoms and 15.5% showed esophagitis; 103 (10%) had suspected CLE, and 12 (1.2%) had a visible segment ≥2 cm. The prevalence of BE in those with reflux symptoms was 2.3% and in those without reflux symptoms was 1.2% (P = .18). In those with esophagitis, the prevalence was 2.6%; in those without, the prevalence was 1.4% (P = .32). Alcohol (P = .04) and smoking (P = .047) were independent risk factors for BE. Conclusions: BE was found in 1.6% of the general Swedish population. Alcohol and smoking were significant risk factors. In Barrett’s esophagus (BE), the normal squamous epithelium in the distal esophagus is replaced by histologically confirmed specialized intestinal metaplasia (SIM).1Spechler S.J. The columnar-lined esophagus. History, terminology, and clinical issues.Gastroenterol Clin North Am. 1997; 26: 455-466Abstract Full Text Full Text PDF PubMed Scopus (60) Google Scholar, 2Hirota W.K. Loughney T.M. Lazas D.J. Maydonovitch C.L. Rholl V. Wong R.K. Specialized intestinal metaplasia, dysplasia, and cancer of the esophagus and esophagogastric junction prevalence and clinical data.Gastroenterology. 1999; 116: 277-285Abstract Full Text Full Text PDF PubMed Scopus (458) Google Scholar, 3Sampliner R.E. Updated guidelines for the diagnosis, surveillance, and therapy of Barrett’s esophagus.Am J Gastroenterol. 2002; 97: 1888-1895Crossref PubMed Google Scholar It is considered one of the most important complications of gastroesophageal reflux disease due to its association with adenocarcinoma.4Falk G.W. Gastroesophageal reflux disease and Barrett’s esophagus.Endoscopy. 2001; 33: 109-118Crossref PubMed Scopus (37) Google Scholar, 5Falk G.W. Barrett’s esophagus.Gastroenterology. 2002; 122: 1569-1591Abstract Full Text Full Text PDF PubMed Scopus (336) Google Scholar Esophageal adenocarcinoma has been estimated to develop in about 0.5%–1.0% of patients with BE annually6O’Connor J.B. Falk G.W. Richter J.E. The incidence of adenocarcinoma and dysplasia in Barrett’s esophagus report on the Cleveland Clinic Barrett’s Esophagus Registry.Am J Gastroenterol. 1999; 94: 2037-2042Crossref PubMed Google Scholar, 7Shaheen N.J. Crosby M.A. Bozymski E.M. Sandler R.S. Is there publication bias in the reporting of cancer risk in Barrett’s esophagus?.Gastroenterology. 2000; 119: 333-338Abstract Full Text Full Text PDF PubMed Scopus (734) Google Scholar, 8Spechler S.J. Clinical practice. Barrett’s Esophagus.N Engl J Med. 2002; 346: 836-842Crossref PubMed Scopus (538) Google Scholar, 9Jankowski J.A. Provenzale D. Moayyedi P. Esophageal adenocarcinoma arising from Barrett’s metaplasia has regional variations in the west.Gastroenterology. 2002; 122: 588-590Abstract Full Text Full Text PDF PubMed Scopus (128) Google Scholar and is now the most rapidly increasing cancer in the Western world.10Blot W.J. Devesa S.S. Kneller R.W. Fraumeni Jr, J.F. Rising incidence of adenocarcinoma of the esophagus and gastric cardia.JAMA. 1991; 265: 1287-1289Crossref PubMed Scopus (2179) Google Scholar, 11Haggitt R.C. Adenocarcinoma in Barrett’s esophagus a new epidemic?.Hum Pathol. 1992; 23: 475-476Abstract Full Text PDF PubMed Scopus (120) Google Scholar, 12Devesa S.S. Blot W.J. Fraumeni Jr, J.F. Changing patterns in the incidence of esophageal and gastric carcinoma in the United States.Cancer. 1998; 83: 2049-2053Crossref PubMed Scopus (1951) Google Scholar Importantly, esophageal adenocarcinoma is often found without any history of reflux symptoms.13Bytzer P. Christensen P.B. Damkier P. Vinding K. Seersholm N. Adenocarcinoma of the esophagus and Barrett’s esophagus a population-based study.Am J Gastroenterol. 1999; 94: 86-91Crossref PubMed Scopus (253) Google ScholarThe figures on prevalence of BE vary considerably.5Falk G.W. Barrett’s esophagus.Gastroenterology. 2002; 122: 1569-1591Abstract Full Text Full Text PDF PubMed Scopus (336) Google Scholar There may be several explanations for this discrepancy, such as the time point of assessment, patient selection, and endoscopic and histologic criteria. In an autopsy study in Olmsted County, Cameron et al14Cameron A.J. Zinsmeister A.R. Ballard D.J. Carney J.A. Prevalence of columnar-lined (Barrett’s) esophagus. Comparison of population-based clinical and autopsy findings.Gastroenterology. 1990; 99: 918-922PubMed Google Scholar found a prevalence of as low as 0.4% in a forensic medicine population. In 1128 consecutive patients with reflux symptoms or dyspepsia referred for endoscopy in primary care, the prevalence was 1% in the whole population and 4.4% in the gastroesophageal reflux disease–enriched population.15Voutilainen M. Sipponen P. Mecklin J.P. Juhola M. Farkkila M. Gastroesophageal reflux disease prevalence, clinical, endoscopic and histopathological findings in 1,128 consecutive patients referred for endoscopy due to dyspeptic and reflux symptoms.Digestion. 2000; 61: 6-13Crossref PubMed Scopus (166) Google Scholar In a German outpatient study of 6215 patients with reflux symptoms, the overall prevalence was reported to be 4.9%; however, in those with esophagitis, 8.4% had BE.16Malfertheiner P. Lind T. Willich S. Vieth M. Jaspersen D. Labenz J. Meyer-Sabellek W. Junghard O. Stolte M. Prognostic influence of Barrett’s oesophagus and Helicobacter pylori infection on healing of erosive gastro-oesophageal (GORD) and symptom resolution in non-erosive GORD report from the ProGORD Study.Gut. 2005; 54: 746-751Crossref PubMed Scopus (84) Google Scholar A remarkably high prevalence of BE of 25% was reported among mainly male veterans without reflux symptoms attending a sigmoidoscopy screening program but who also underwent an upper gastrointestinal endoscopy.17Gerson L.B. Shetler K. Triadafilopoulos G. Prevalence of Barrett’s esophagus in asymptomatic individuals.Gastroenterology. 2002; 123: 461-467.Abstract Full Text Full Text PDF PubMed Scopus (401) Google Scholar Similarly, in a colonoscopy screening program, Rex et al found a prevalence of BE of 8.3%, with long segment in 2.6% of those with reflux symptoms, compared with 5.6% and 0.4%, respectively, of those without reflux symptoms.18Rex D.K. Cummings O.W. Shaw M. Cumings M.D. Wong R.K. Vasudeva R.S. Dunne D. Rahmani E.Y. Helper D.J. Screening for Barrett’s esophagus in colonoscopy patients with and without heartburn.Gastroenterology. 2003; 125: 1670-1677Abstract Full Text Full Text PDF PubMed Scopus (408) Google Scholar Although these studies all evaluated selected populations, they have emphasized a presumptive huge public health problem. To target the problem adequately, data from an unbiased general population are required and have not been available to date.The aim of this study was to determine the prevalence of BE and associated risk factors in the adult general population, irrespective of reflux symptoms.Patients and MethodsSettingThe setting consisted of 2 neighboring communities in northern Sweden, Kalix and Haparanda, with 18,408 and 10,580 inhabitants, respectively (as of December 1998). The age and sex distribution was similar to the national average in Sweden.19Aro P. Ronkainen J. Storskrubb T. Bolling-Sternevald E. Carlsson R. Johansson S.E. Vieth M. Stolte M. Engstrand L. Talley N.J. Agreus L. Valid symptom reporting at upper endoscopy in a random sample of the Swedish adult general population the Kalixanda study.Scand J Gastroenterol. 2004; 39: 1280-1288Crossref PubMed Scopus (73) Google ScholarThis study was approved by the Umeå University Ethics Committee and conducted in accordance with the revised Declaration of Helsinki in 1998.SamplingBy using the computerized national population register, covering all citizens in the 2 communities by date of birth order, a representative sample was generated. Every seventh adult (n = 3000) from the target population (20–80 years of age, n = 21,610 in September 1998) was drawn, a procedure equivalent to random sampling. The sampled subjects were then, by a computerized process, given an identification number (ID 1–3000) in random order.Study Design and LogisticsThe study population (n = 3000) was contacted by mail and invited to take part; this invitation included a validated questionnaire, the Abdominal Symptom Questionnaire,20Agréus L. Svärdsudd K. Nyrén O. Tibblin G. Reproducibility and validity of a postal questionnaire. The abdominal symptom study.Scand J Prim Health Care. 1993; 11: 252-262Crossref PubMed Scopus (80) Google Scholar, 21Aro P. Ronkainen J. Storskrubb T. Bolling-Sternevald E. Svardsudd K. Talley N.J. Junghard O. Johansson S.E. Wiklund I. Agréus L. Validation of the translation and cross-cultural adaptation into Finnish of the Abdominal Symptom Questionnaire, the Hospital Anxiety and Depression Scale and the Complaint Score Questionnaire.Scand J Gastroenterol. 2004; 39: 1201-1208Crossref PubMed Scopus (29) Google Scholar to be returned by mail. A total of 2860 subjects were available at the time for invitation.19Aro P. Ronkainen J. Storskrubb T. Bolling-Sternevald E. Carlsson R. Johansson S.E. Vieth M. Stolte M. Engstrand L. Talley N.J. Agreus L. Valid symptom reporting at upper endoscopy in a random sample of the Swedish adult general population the Kalixanda study.Scand J Gastroenterol. 2004; 39: 1280-1288Crossref PubMed Scopus (73) Google ScholarWe aimed to perform an esophagogastroduodenoscopy (EGD) in one third of the study population, that is, 1000 individuals who formed the EGD study sample (4.6% of the target population). The participants were invited to a visit in the clinic in identification number order, for logistic reasons during a 2.5-year period, starting with the lowest available identification number.At the EGD visit, the participants were asked about their consumption of aspirin, nonsteroidal anti-inflammatory drugs, antacids, H2-receptor antagonists, and proton pump inhibitors over the past 3 months and about their tobacco (smoking or snuff) and alcohol use. A venous blood sample for Helicobacter pylori serology was also taken. Details regarding study logistics, sampling procedure, and baseline demographics were reported previously.19Aro P. Ronkainen J. Storskrubb T. Bolling-Sternevald E. Carlsson R. Johansson S.E. Vieth M. Stolte M. Engstrand L. Talley N.J. Agreus L. Valid symptom reporting at upper endoscopy in a random sample of the Swedish adult general population the Kalixanda study.Scand J Gastroenterol. 2004; 39: 1280-1288Crossref PubMed Scopus (73) Google Scholar, 22Ronkainen J. Aro P. Storskrubb T. Johansson S.E. Lind T. Bolling-Sternevald E. Graffner H. Vieth M. Stolte M. Engstrand L. Talley N.J. Agréus L. High prevalence of gastroesophageal reflux symptoms and esophagitis with or without symptoms in the general adult Swedish population a Kalixanda study report.Scand J Gastroenterol. 2005; 40: 275-285Crossref PubMed Scopus (344) Google ScholarQuestionnaire and Response RateThe Abdominal Symptom Questionnaire used in this investigation has been validated and previously described in detail.19Aro P. Ronkainen J. Storskrubb T. Bolling-Sternevald E. Carlsson R. Johansson S.E. Vieth M. Stolte M. Engstrand L. Talley N.J. Agreus L. Valid symptom reporting at upper endoscopy in a random sample of the Swedish adult general population the Kalixanda study.Scand J Gastroenterol. 2004; 39: 1280-1288Crossref PubMed Scopus (73) Google Scholar, 20Agréus L. Svärdsudd K. Nyrén O. Tibblin G. Reproducibility and validity of a postal questionnaire. The abdominal symptom study.Scand J Prim Health Care. 1993; 11: 252-262Crossref PubMed Scopus (80) Google Scholar, 21Aro P. Ronkainen J. Storskrubb T. Bolling-Sternevald E. Svardsudd K. Talley N.J. Junghard O. Johansson S.E. Wiklund I. Agréus L. Validation of the translation and cross-cultural adaptation into Finnish of the Abdominal Symptom Questionnaire, the Hospital Anxiety and Depression Scale and the Complaint Score Questionnaire.Scand J Gastroenterol. 2004; 39: 1201-1208Crossref PubMed Scopus (29) Google Scholar The cutoff for reporting symptoms was that the symptoms should have been at least troublesome at some time during the past 3 months. An extended Abdominal Symptom Questionnaire with added symptom frequency evaluation (daily, weekly, past 3 months) was completed by the EGD study sample (n = 1000) immediately before the endoscopy.A total of 2122 individuals completed the postal questionnaire, which corresponds to a response rate of 74% after 2 postal reminders. These responders were representative of the local population.To complete the 1000 upper endoscopies, 1563 responders to the Abdominal Symptom Questionnaire were approached; 364 declined, 74 had moved or could not be reached, 124 had medical contraindications, and 1 refused biopsy. Thus, the response rate for those eligible for investigation was 73%. The EGD study sample (mean age, 53.5 years; 51% female) was significantly older than the study population (by a mean of 3.7 years; P < .01), mainly due to a lower response rate among the symptom-free youngest one fourth of the study sample, but there was no statistically significant difference in sex distribution. In total, the sex and age distribution for the 1000 subjects who responded to the questionnaire at both assessments closely reflects the 2122 responders to the postal questionnaire and the Swedish population, as described in detail previously.19Aro P. Ronkainen J. Storskrubb T. Bolling-Sternevald E. Carlsson R. Johansson S.E. Vieth M. Stolte M. Engstrand L. Talley N.J. Agreus L. Valid symptom reporting at upper endoscopy in a random sample of the Swedish adult general population the Kalixanda study.Scand J Gastroenterol. 2004; 39: 1280-1288Crossref PubMed Scopus (73) Google Scholar Hence, a representative cohort of 1000 subjects invited for an upper endoscopy was evaluated.EndoscopyThe EGDs in the survey were provided by 2 endoscopists in primary care and 1 endoscopist in secondary care; the 2 endoscopy units cover the whole catchment area. Before endoscopy, the 3 endoscopists were blinded to the medical history and symptoms. In Haparanda, an Olympus XQ-20 fiber endoscope (Olympus Co., Tokyo, Japan) was used; in Kalix, an Olympus GIF-100 videoendoscope (Olympus Co.) was used. To achieve endoscopic assessment reliability, the endoscopists participated in training sessions focusing on assessment of BE and esophagitis.19Aro P. Ronkainen J. Storskrubb T. Bolling-Sternevald E. Carlsson R. Johansson S.E. Vieth M. Stolte M. Engstrand L. Talley N.J. Agreus L. Valid symptom reporting at upper endoscopy in a random sample of the Swedish adult general population the Kalixanda study.Scand J Gastroenterol. 2004; 39: 1280-1288Crossref PubMed Scopus (73) Google Scholar, 22Ronkainen J. Aro P. Storskrubb T. Johansson S.E. Lind T. Bolling-Sternevald E. Graffner H. Vieth M. Stolte M. Engstrand L. Talley N.J. Agréus L. High prevalence of gastroesophageal reflux symptoms and esophagitis with or without symptoms in the general adult Swedish population a Kalixanda study report.Scand J Gastroenterol. 2005; 40: 275-285Crossref PubMed Scopus (344) Google ScholarThe gastroesophageal junction was defined as the junction of the proximal gastric folds and the tubular esophagus. In addition, hiatus hernia was recorded in the predefined protocol.Definitions of BE, Esophagitis, and Reflux SymptomsAt endoscopy, BE was searched for when a suspected columnar-lined esophagus (CLE) was identified based on salmon-pink mucosa in either a circumferential upward shift of the squamocolumnar junction or in adjacent mucosal tongues3Sampliner R.E. Updated guidelines for the diagnosis, surveillance, and therapy of Barrett’s esophagus.Am J Gastroenterol. 2002; 97: 1888-1895Crossref PubMed Google Scholar, 14Cameron A.J. Zinsmeister A.R. Ballard D.J. Carney J.A. Prevalence of columnar-lined (Barrett’s) esophagus. Comparison of population-based clinical and autopsy findings.Gastroenterology. 1990; 99: 918-922PubMed Google Scholar or islands.23Wallner B. Sylvan A. Stenling R. Janunger K.G. The esophageal Z-line appearance correlates to the prevalence of intestinal metaplasia.Scand J Gastroenterol. 2000; 35: 17-22Crossref PubMed Scopus (37) Google Scholar The diagnosis of BE was based on the endoscopic finding of suspected CLE in the distal esophagus, confirmed by the presence of SIM in the esophageal biopsy specimens.1Spechler S.J. The columnar-lined esophagus. History, terminology, and clinical issues.Gastroenterol Clin North Am. 1997; 26: 455-466Abstract Full Text Full Text PDF PubMed Scopus (60) Google Scholar, 2Hirota W.K. Loughney T.M. Lazas D.J. Maydonovitch C.L. Rholl V. Wong R.K. Specialized intestinal metaplasia, dysplasia, and cancer of the esophagus and esophagogastric junction prevalence and clinical data.Gastroenterology. 1999; 116: 277-285Abstract Full Text Full Text PDF PubMed Scopus (458) Google Scholar, 24Spechler S.J. Columnar-lined esophagus. Definitions.Chest Surg Clin North Am. 2002; 12 (vii): 1-13Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar It was defined as long-segment BE (LSBE) if the segment was ≥2 cm long and short-segment BE (SSBE) if it was <2 cm.25McClave S.A. Boyce Jr, H.W. Gottfried M.R. Early diagnosis of columnar-lined esophagus a new endoscopic diagnostic criterion.Gastrointest Endosc. 1987; 33: 413-416Abstract Full Text PDF PubMed Scopus (219) Google Scholar, 26Gottfried M.R. McClave S.A. Boyce H.W. Incomplete intestinal metaplasia in the diagnosis of columnar lined esophagus (Barrett’s esophagus).Am J Clin Pathol. 1989; 92: 741-746PubMed Google Scholar, 27Lieberman D. Fennerty M.B. Morris C.D. Holub J. Eisen G. Sonnenberg A. Endoscopic evaluation of patients with dyspepsia results from the national endoscopic data repository.Gastroenterology. 2004; 127: 1067-1075Abstract Full Text Full Text PDF PubMed Scopus (81) Google ScholarFurthermore, esophageal mucosal breaks (esophagitis) were graded according to the Los Angeles classification system.28Armstrong D. Bennett J.R. Blum A.L. Dent J. De Dombal F.T. Galmiche J.P. Lundell L. Margulies M. Richter J.E. Spechler S.J. Tytgat G.N. Wallin L. The endoscopic assessment of esophagitis a progress report on observer agreement.Gastroenterology. 1996; 111: 85-92Abstract Full Text Full Text PDF PubMed Scopus (905) Google Scholar, 29Lundell L.R. Dent J. Bennett J.R. Blum A.L. Armstrong D. Galmiche J.P. Johnson F. Hongo M. Richter J.E. Spechler S.J. Tytgat G.N. Wallin L. Endoscopic assessment of oesophagitis clinical and functional correlates and further validation of the Los Angeles classification.Gut. 1999; 45: 172-180Crossref PubMed Scopus (1654) Google ScholarGastroesophageal reflux symptoms were defined as troublesome heartburn and/or acid regurgitation over the past 3 months.22Ronkainen J. Aro P. Storskrubb T. Johansson S.E. Lind T. Bolling-Sternevald E. Graffner H. Vieth M. Stolte M. Engstrand L. Talley N.J. Agréus L. High prevalence of gastroesophageal reflux symptoms and esophagitis with or without symptoms in the general adult Swedish population a Kalixanda study report.Scand J Gastroenterol. 2005; 40: 275-285Crossref PubMed Scopus (344) Google Scholar, 30Klauser A.G. Schindlbeck N.E. Müller-Lissner S.A. Symptoms in gastro-oesophageal reflux disease.Lancet. 1990; 335: 205-208Abstract PubMed Scopus (699) Google ScholarBiopsy SpecimensAccording to the protocol, at least 2 biopsy specimens were taken from the following locations in the esophagus: 2 cm above the Z-line, at the Z-line, and with an inverted endoscope at the cardia adjacent to the Z-line, with the aim of obtaining both squamous and columnar epithelium in the biopsy specimens from the last 2 locations. In addition, 2 or more biopsy specimens were taken from any suspected CLE areas. In the stomach, biopsy specimens were obtained according to the recommendations of the updated Sydney System31Dixon M.F. Genta R.M. Yardley J.H. Correa P. Classification and grading of gastritis. The updated Sydney System. International Workshop on the Histopathology of Gastritis, Houston 1994.Am J Surg Pathol. 1996; 20: 1161-1181Crossref PubMed Scopus (4369) Google Scholar and for culture of H pylori.Biopsy specimens were independently examined by 2 experienced gastrointestinal pathologists (M.V. and M.S.) who were blinded to the clinical data and endoscopic findings. Biopsy specimens were stained with H&E, and those from the stomach were also stained with Warthin–Starry silver stain.The diagnosis of BE was made only if SIM characterized by the presence of goblet cells could be identified. Complete intestinal metaplasia32Voutilainen M. Farkkila M. Juhola M. Mecklin J.P. Sipponen P. Complete and incomplete intestinal metaplasia at the oesophagogastric junction prevalences and associations with endoscopic erosive oesophagitis and gastritis.Gut. 1999; 45: 644-648Crossref PubMed Scopus (53) Google Scholar of the cardia mucosa was not included in the definition.Histologic features of the gastric mucosa, such as inflammation and atrophy, were recorded and scored according to the updated Sydney System.31Dixon M.F. Genta R.M. Yardley J.H. Correa P. Classification and grading of gastritis. The updated Sydney System. International Workshop on the Histopathology of Gastritis, Houston 1994.Am J Surg Pathol. 1996; 20: 1161-1181Crossref PubMed Scopus (4369) Google ScholarFor identification of H pylori, histology and culture were used (for details, see Storskrubb et al33Storskrubb T. Aro P. Ronkainen J. Vieth M. Stolte M. Wreiber K. Engstrand L. Nyhlin H. Bolling-Sternevald E. Talley N.J. Agréus L. A negative Helicobacter pylori serology test is more reliable for exclusion of premalignant gastric conditions than a negative test for current H. pylori infection a report on histology and H. pylori detection in the general adult population.Scand J Gastroenterol. 2005; 40: 302-311Crossref PubMed Scopus (42) Google Scholar). The subject was considered to have a current infection if histology and/or culture detected the bacteria.Laboratory AnalysisBlood samples were taken for assessment of H pylori serology. H pylori antibodies of immunoglobulin G were determined by enzyme immunoassay (Pyloriset EIA-G; Orion Diagnostica, Espoo, Finland) at the Institute for Infectious Disease Control (Stockholm, Sweden).33Storskrubb T. Aro P. Ronkainen J. Vieth M. Stolte M. Wreiber K. Engstrand L. Nyhlin H. Bolling-Sternevald E. Talley N.J. Agréus L. A negative Helicobacter pylori serology test is more reliable for exclusion of premalignant gastric conditions than a negative test for current H. pylori infection a report on histology and H. pylori detection in the general adult population.Scand J Gastroenterol. 2005; 40: 302-311Crossref PubMed Scopus (42) Google ScholarStatisticsP values were all 2 tailed, and the α level of significance was set at 0.05. The prevalence is shown as a percentage with a 95% confidence interval (CI). Fisher exact test and likelihood ratio χ2 test were used for testing comparison in univariate analyses. Correlations were tested with the Spearman correlation test.Due to the low number of cases of BE, it was analyzed using Fisher exact test and a univariate logistic regression model adjusted for age (dichotomized at 50 years) and sex.34Kleinbaum D.G. Logistic regression a self-learning text. 2nd ed. Springer Verlag, New York, NY2002Google Scholar The results are shown as odds ratios (ORs) with 95% CIs. The reference group was given an OR of 1. The goodness of fit of the models was judged from the Pearson χ2 test and degrees of freedom, which should be about equal. The fit of the model was considered to be acceptable with P ≥ .05. Age was tested for linearity. The Intercooled Stata 8 program35Stata. CorpStata statistical software. Stata Corp, College Station, TX2003Google Scholar was used for the analyses.Age; sex; hiatus hernia; esophagitis; obesity36World Health OrganizationObesity preventing and managing the global epidemic.WHO Technical Report Series, No. 894. World Health Organization, Geneva, Switzerland1997Google Scholar; reflux symptoms; alarm symptoms (weight loss, dysphagia, anemia, hematochezia); use of tobacco (smoking or snuff); use of alcohol; use of nonsteroidal anti-inflammatory drugs or aspirin; use of antacids/alginates, H2-receptor antagonists, or proton pump inhibitors; current H pylori infection; serologic scar but no current infection with H pylori33Storskrubb T. Aro P. Ronkainen J. Vieth M. Stolte M. Wreiber K. Engstrand L. Nyhlin H. Bolling-Sternevald E. Talley N.J. Agréus L. A negative Helicobacter pylori serology test is more reliable for exclusion of premalignant gastric conditions than a negative test for current H. pylori infection a report on histology and H. pylori detection in the general adult population.Scand J Gastroenterol. 2005; 40: 302-311Crossref PubMed Scopus (42) Google Scholar; chemical gastritis; atrophy of corpus or antrum mucosa; corpus-dominant H pylori gastritis; and education were included in the models as possible positive or negative risk factors for BE.ResultsEndoscopySuspected CLE was found in 103 cases (10.3%; mean age, 55.7 years; 60.2% men). Twelve of them (1.2%) with a mean age of 59 years (7 men) had a long segment. Of the 87 suspected CLE cases without SIM in the biopsy specimens, there were 83 cases with columnar epithelium, 3 with squamous epithelium, and 1 with missing biopsy specimens. Hence, 96.1% of the suspected CLE had columnar epithelium in the biopsy specimens. On biopsy specimens from the distal esophagus and gastroesophageal junction, 60 were positive for SIM in total.Esophagitis was found in 155 cases (109 Los Angeles grade A, 39 grade B, 3 grade C, and 2 grade D; missing classification in 2 cases).BEBE was found in 16 individuals (1.6%) with a mean age of 57 years (9 men). LSBE occurred in 5 individuals (0.5%) with a mean age of 58 years, and 3 (60%) were men. SSBE occurred in 11 individuals (1.1%) with a mean age of 56 years, and 6 (54.6%) were men (Table 1). The age distribution by sex is shown in Table 2. The mean age of the men with BE was 52.2 years (5 of 9 younger than 50 years of age) compared with the mean age of 63 years for women with BE (6 of 7 older than 50 years of age).Table 1Prevalence of BE and Prevalence of Gastroesophageal Reflux Symptoms and Esophagitis With BE or Without BEBELSBESSBENo BENo. of cases (%)16 (1.6)5 (0.5)11 (1.1)984 (98.4) % with gastroesophageal reflux symptoms56.380.045.539.7 % with esophagitis25.060.09.115.4NOTE. n = 1000. Open table in a new tab Table 2Prevalence of BE by Age Group and SexAge group (y)20–3435–4950–64Older than 65TotalMen14229Women01157Total153716 Open table in a new tab An endoscopic finding of suspected CLE was correlated to the histologic finding of SIM (Spearman ρ = 0.14; P < .01). The prevalence of SIM in the esophageal biopsy specimens was higher if the length of the suspected CLE was longer: 41.7% in segments ≥2 cm, 12.1% in segments <2 cm, and 4.5% without a visible suspected CLE segment (P = .01 in segments ≥2 cm vs segments <2 cm, P < .01 in segments <2 cm vs no visible segment, and P < .01 in segments ≥2 cm vs no visible segment, respectively).Suspected CLE was not statistically significantly associated with reflux symptoms reported daily, wee
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