Classical Barrett Esophagus Contrasted with Barrett-Type Epithelium at Normal-Appearing Esophagogastric Junction: Comparison of Demographic, Endoscopic, and Histologic Features

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Abstract
Incomplete intestinal metaplasia or specialized columnar epithelium (SCE) is the histologic hallmark of Barrett esophagus (BE), but it may also occur at a normal-appearing gastroesophageal junction without BE. We studied whether differences occur between BE patients and those with SCE at the squamocolumnar junction but without BE (abbreviated JSCE), in terms of endoscopic and histologic signs of gastroesophageal reflux disease (GERD) and Helicobacter pylori gastritis. A total of 1059 consecutive patients referred for endoscopy in one hospital district in Finland were enrolled in the study. Biopsy specimens (at least two from each site) were obtained from the gastric antrum and the corpus of the stomach and from the esophagogastric junction and distal esophagus. Classical BE was detected in 25 (2%) and JSCE in 99 (9%) patients. Dysplasia in the metaplastic mucosa was observed in six BE patients but in none of the JSCE patients (P < 0.001). In multivariate analysis the independent risk factors for BE were endoscopic erosive esophagitis (odds ratio (OR), 6.08; 95% confidence interval (CI), 2.50-14.82), male sex (OR, 3.02; 95% CI, 1.20-7.65), and age (OR, 1.02 per year; 95% CI, 1.00-1.06). The independent risk factors for JSCE were endoscopic erosive esophagitis (OR, 1.88; 95% CI, 1.08-3.29) and age (OR, 1.03; 95% CI, 1.02-1.05) but not H. pylori infection (OR, 1.57; 95% CI, 0.83-2.97) or chronic gastritis (OR, 0.88; 95% CI, 0.44-1.75). In univariate analysis, however, JSCE was associated with antral-predominant atrophic gastritis (77% H. pylori-positive). Unlike in JSCE patients, male sex strongly predominated among BE patients (P = 0.01). The mean ages of BE and JSCE patients did not differ. Both BE and JSCE without BE increase in prevalence with age, and both associate with endoscopic erosive esophagitis but not with H. pylori gastritis. However, because of the marked sex disparity, JSCE cannot be a direct precursor of BE, and some factors other than GERD alone also play a role in the pathogenesis of BE. Compared with BE, dysplasia is a rare finding in JSCE, and endoscopic surveillance with biopsy specimens from JSCE patients without dysplasia is not recommended.