Scandinavian Journal of Gastroenterology. 2014; 49: 138–144
ORIGINAL ARTICLE
Heterotopic gastric mucosa of the gastrointestinal tract: prevalence, histological features, and clinical characteristics
Scand J Gastroenterol Downloaded from informahealthcare.com by University of Nebraska on 11/06/14 For personal use only.
LAN YU1,2,*, YUNSHENG YANG1,*, LIHONG CUI2,*, LIHUA PENG1 & GANG SUN1 1
Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing, China, and 2Department of Gastroenterology, Chinese PLA NAVY General Hospital, Beijing, China
Abstract Background. Heterotopic gastric mucosa (HGM) may be located at sites throughout the gastrointestinal (GI) tract. Clinical characteristics of HGM, role of Helicobacter pylori infection, natural history, and relationship to neoplastic transformation have not sufficiently been explored. Aim. To retrospectively study the prevalence, histological features, and clinical characteristics of HGM among Chinese patients who underwent upper GI endoscopy. Methods. Endoscopic, histological, and clinical records of patients, who underwent upper GI endoscopy (n = 6802) and colonoscopy (n = 3504), respectively, between May 2011 and May 2012, were collected and retrospectively analyzed. A total of 6716 sex- and age-matched patients without HGM were enrolled as controls. Results. HGM was diagnosed in 86 cases (51 esophageal, 0.75%; 35 duodenal, 0.51%). Male: female ratio was 1.4:1 (30/21) for esophageal HGM, 1.7:1 (22/13) for duodenal HGM, and 1.1:1 (3557/3159) for controls. Two histopathological types of HGM were identified: foveolar epithelium alone and foveoloar epithelium together with gastric glands. Helicobacter pylori were present in 19.6% of cases with esophageal HGM and 20.0% of cases with duodenal HGM. Esophageal HGM was significantly associated with dysphagia and globus; duodenal HGM was not significantly associated with GI symptoms. Intestinal metaplasia was present in two and three patients in both groups, respectively, with no dysplasia or carcinoma. Conclusion. HGM was present in fewer patients undergoing upper GI endoscopy, and it was more often present in men. A careful endoscopic examination is required to diagnose HGM, and it should be supported with a biopsy when indicated.
Key Words: dysphagia, endoscopy, globus, heterotopic gastric mucosa, prevalence
Introduction Heterotopic gastric mucosa (HGM) was first reported by Schmidt et al. [1] as a salmon-colored patch, usually located in the proximal esophagus and often referred as inlet patch. Since then, HGM has been reported in many other parts of gastrointestinal tract: duodenum [2], Meckel’s diverticulum [3], colorectum [4], and gallbladder [5]. The reported prevalence of esophageal HGM varies widely from 0.1 to 13.8% [6,7], and duodenal HGM varies from 0.5 to 8.9% [8,9]. HGM is generally considered to be congenital in nature, but sometimes it may be an acquired condition [10]. Esophageal HGM is usually asymptomatic;
but it can present with upper esophageal and laryngopharyngeal symptoms such as dysphagia, globus, retrosternal pain, heartburn, and hoarseness [11,12]. Clinically significant complications related to acid secretion such as bleeding, ulceration, stricture, and fistulization have also been reported in esophageal HGM [11]. Reports on duodenal HGM are few [13], and no study has explored any symptoms associated with duodenal HGM. Rare cases of dysplastic changes and malignancies have also been reported in HGM [10,14-16]. Reports on HGM from China are also relatively few. The following on HGM are still unknown: clinical characteristics, role of Helicobacter pylori infection, natural history, and relationship to
Correspondence: Yunsheng Yang, Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, No. 28 Fuxing Road, Beijing 100853, China. Tel: +86 13810845375; Fax: +86 21 64085875. E-mail: [email protected]
(Received 28 August 2013; revised 23 October 2013; accepted 25 October 2013) ISSN 0036-5521 print/ISSN 1502-7708 online 2014 Informa Healthcare DOI: 10.3109/00365521.2013.860558
Characteristics of heterotopic gastric mucosa
139
Patients underwent upper gastrointestinal endoscopy n = 6807
5 Patients excluded: 4 Lack of pathological data 1 Incomplete medical record
Scand J Gastroenterol Downloaded from informahealthcare.com by University of Nebraska on 11/06/14 For personal use only.
Patients underwent upper gastrointestinal endoscopy enrolled n = 6802
Patients with HGM n = 86
Patients with esophgeal HGM n = 51
Patients without HGM n = 6716
Patients with duodenal HGM n = 35
Figure 1. Flow chart of patients enrolled in the study. HGM, heterotopic gastric mucosa.
neoplastic transformation. Hence, this study aimed to identify the prevalence, histological features, and clinical characteristics of HGM among Chinese population.
based on demographic characteristics (sex- and agematched) irrespective of their endoscopic diagnosis.
Patients and methods
Statistical analysis was performed with SPSS software version 13.0 (SPSS Inc, Chicago, Illinois). Mean age of patients was mentioned as mean ± standard deviation (SD). Independent samples t-test was performed for continuous variables. Chi-square and Fisher exact tests were used for detecting significant differences in the percentage of categorical data. A pValue < 0.05 was considered as statistically significant.
Study design
Statistical analysis
This study involved a retrospective analysis of medical records (endoscopic, histological, and clinical records) and was conducted at the Gastrointestinal Endoscopic Center of the People’s Liberation Army Navy General Hospital, Beijing, China, between May 2011 and May 2012.
Results
Study population, data collection, and selection criteria
Demographic characteristics
Chinese patients who underwent upper gastrointestinal endoscopy (n = 6807) and colonoscopy (n = 3504), respectively, at the center were identified, and their endoscopic and corresponding histological reports were collected and analyzed from computer database. Five patients who underwent upper gastrointestinal endoscopy were excluded due to the lack of relevant pathological data or medical records (Figure 1). In order to help determine whether HGM was associated with clinical symptoms and other endoscopic findings, 6716 patients without HGM were randomly selected in the control group
Among the 6802 patients who underwent upper gastrointestinal endoscopy and had complete medical records (mean age: 44.3 ± 12.8 years), the condition of 86 patients were diagnosed with HGM; of which, 51 patients (30 male and 21 female) (51/6802, 0.75%) were found to have esophageal HGM and 35 patients (22 male and 13 female) (35/6802, 0.51%) were found to have histologically confirmed duodenal HGM. Male:female ratio was 1.4:1 in patients with esophageal HGM, 1.7:1 in patients with duodenal HGM, and 1.1:1 in patients without HGM, respectively (both p < 0.01). The mean age was 43.6 ±
140
L. Yu et al.
Table I. Demographic characteristics of patients with or without HGM. HGM (+) Esophagus (n = 51)
Duodenum (n = 35)
HGM (–) (n = 6716)
Total (n = 6802)
Scand J Gastroenterol Downloaded from informahealthcare.com by University of Nebraska on 11/06/14 For personal use only.
Male 30 (58.8%) 22 (62.9%) 3557 (53.0%) 3614 (53.1%) Female 21 (41.2%)* 13 (37.1%)* 3159 (47.0%) 3193 (46.9%) Mean 43.6 ± 12.8# 41.3 ± 11.4# 44.5 ± 13.5 44.3 ± 12.8 age (years) HGM(+): Patients with HGM; HGM(–): Patients without HGM. * p < 0.01 patients with HGM (+) vs. patients without HGM (–). # p > 0.05 patients with HGM (+) vs. patients without HGM (–).
12.8 years in patients with esophageal HGM, 41.3 ± 11.4 years in patients with duodenal HGM, and 44.5 ± 13.5 years in patients without HGM (n = 6716), respectively (both p > 0.05) (Table I). During the study period, HGM was not diagnosed in all the 3504 patients who underwent colonoscopy. Endoscopic features Esophageal HGM. In patients with HGM of esophageal origin, HGM appeared as a round or oval salmon-colored patch and was located distal to upper esophageal sphincter (16–22 cm from the frontal incisor teeth). Twenty-eight patients (54.9%) had one patch, and 23 patients (45.1%) had two or more patches. Mean greatest diameter of HGM was 2–20 mm. No ulcer, bleeding, or stricture was found to be associated with HGM. Neutral beam injection imaging of an esophageal HGM patch is presented in Figure 2. Duodenal HGM. In patients with HGM of duodenal origin, HGM was appeared as a hemispherical solitary polyp (
ORIGINAL ARTICLE
Heterotopic gastric mucosa of the gastrointestinal tract: prevalence, histological features, and clinical characteristics
Scand J Gastroenterol Downloaded from informahealthcare.com by University of Nebraska on 11/06/14 For personal use only.
LAN YU1,2,*, YUNSHENG YANG1,*, LIHONG CUI2,*, LIHUA PENG1 & GANG SUN1 1
Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing, China, and 2Department of Gastroenterology, Chinese PLA NAVY General Hospital, Beijing, China
Abstract Background. Heterotopic gastric mucosa (HGM) may be located at sites throughout the gastrointestinal (GI) tract. Clinical characteristics of HGM, role of Helicobacter pylori infection, natural history, and relationship to neoplastic transformation have not sufficiently been explored. Aim. To retrospectively study the prevalence, histological features, and clinical characteristics of HGM among Chinese patients who underwent upper GI endoscopy. Methods. Endoscopic, histological, and clinical records of patients, who underwent upper GI endoscopy (n = 6802) and colonoscopy (n = 3504), respectively, between May 2011 and May 2012, were collected and retrospectively analyzed. A total of 6716 sex- and age-matched patients without HGM were enrolled as controls. Results. HGM was diagnosed in 86 cases (51 esophageal, 0.75%; 35 duodenal, 0.51%). Male: female ratio was 1.4:1 (30/21) for esophageal HGM, 1.7:1 (22/13) for duodenal HGM, and 1.1:1 (3557/3159) for controls. Two histopathological types of HGM were identified: foveolar epithelium alone and foveoloar epithelium together with gastric glands. Helicobacter pylori were present in 19.6% of cases with esophageal HGM and 20.0% of cases with duodenal HGM. Esophageal HGM was significantly associated with dysphagia and globus; duodenal HGM was not significantly associated with GI symptoms. Intestinal metaplasia was present in two and three patients in both groups, respectively, with no dysplasia or carcinoma. Conclusion. HGM was present in fewer patients undergoing upper GI endoscopy, and it was more often present in men. A careful endoscopic examination is required to diagnose HGM, and it should be supported with a biopsy when indicated.
Key Words: dysphagia, endoscopy, globus, heterotopic gastric mucosa, prevalence
Introduction Heterotopic gastric mucosa (HGM) was first reported by Schmidt et al. [1] as a salmon-colored patch, usually located in the proximal esophagus and often referred as inlet patch. Since then, HGM has been reported in many other parts of gastrointestinal tract: duodenum [2], Meckel’s diverticulum [3], colorectum [4], and gallbladder [5]. The reported prevalence of esophageal HGM varies widely from 0.1 to 13.8% [6,7], and duodenal HGM varies from 0.5 to 8.9% [8,9]. HGM is generally considered to be congenital in nature, but sometimes it may be an acquired condition [10]. Esophageal HGM is usually asymptomatic;
but it can present with upper esophageal and laryngopharyngeal symptoms such as dysphagia, globus, retrosternal pain, heartburn, and hoarseness [11,12]. Clinically significant complications related to acid secretion such as bleeding, ulceration, stricture, and fistulization have also been reported in esophageal HGM [11]. Reports on duodenal HGM are few [13], and no study has explored any symptoms associated with duodenal HGM. Rare cases of dysplastic changes and malignancies have also been reported in HGM [10,14-16]. Reports on HGM from China are also relatively few. The following on HGM are still unknown: clinical characteristics, role of Helicobacter pylori infection, natural history, and relationship to
Correspondence: Yunsheng Yang, Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, No. 28 Fuxing Road, Beijing 100853, China. Tel: +86 13810845375; Fax: +86 21 64085875. E-mail: [email protected]
(Received 28 August 2013; revised 23 October 2013; accepted 25 October 2013) ISSN 0036-5521 print/ISSN 1502-7708 online 2014 Informa Healthcare DOI: 10.3109/00365521.2013.860558
Characteristics of heterotopic gastric mucosa
139
Patients underwent upper gastrointestinal endoscopy n = 6807
5 Patients excluded: 4 Lack of pathological data 1 Incomplete medical record
Scand J Gastroenterol Downloaded from informahealthcare.com by University of Nebraska on 11/06/14 For personal use only.
Patients underwent upper gastrointestinal endoscopy enrolled n = 6802
Patients with HGM n = 86
Patients with esophgeal HGM n = 51
Patients without HGM n = 6716
Patients with duodenal HGM n = 35
Figure 1. Flow chart of patients enrolled in the study. HGM, heterotopic gastric mucosa.
neoplastic transformation. Hence, this study aimed to identify the prevalence, histological features, and clinical characteristics of HGM among Chinese population.
based on demographic characteristics (sex- and agematched) irrespective of their endoscopic diagnosis.
Patients and methods
Statistical analysis was performed with SPSS software version 13.0 (SPSS Inc, Chicago, Illinois). Mean age of patients was mentioned as mean ± standard deviation (SD). Independent samples t-test was performed for continuous variables. Chi-square and Fisher exact tests were used for detecting significant differences in the percentage of categorical data. A pValue < 0.05 was considered as statistically significant.
Study design
Statistical analysis
This study involved a retrospective analysis of medical records (endoscopic, histological, and clinical records) and was conducted at the Gastrointestinal Endoscopic Center of the People’s Liberation Army Navy General Hospital, Beijing, China, between May 2011 and May 2012.
Results
Study population, data collection, and selection criteria
Demographic characteristics
Chinese patients who underwent upper gastrointestinal endoscopy (n = 6807) and colonoscopy (n = 3504), respectively, at the center were identified, and their endoscopic and corresponding histological reports were collected and analyzed from computer database. Five patients who underwent upper gastrointestinal endoscopy were excluded due to the lack of relevant pathological data or medical records (Figure 1). In order to help determine whether HGM was associated with clinical symptoms and other endoscopic findings, 6716 patients without HGM were randomly selected in the control group
Among the 6802 patients who underwent upper gastrointestinal endoscopy and had complete medical records (mean age: 44.3 ± 12.8 years), the condition of 86 patients were diagnosed with HGM; of which, 51 patients (30 male and 21 female) (51/6802, 0.75%) were found to have esophageal HGM and 35 patients (22 male and 13 female) (35/6802, 0.51%) were found to have histologically confirmed duodenal HGM. Male:female ratio was 1.4:1 in patients with esophageal HGM, 1.7:1 in patients with duodenal HGM, and 1.1:1 in patients without HGM, respectively (both p < 0.01). The mean age was 43.6 ±
140
L. Yu et al.
Table I. Demographic characteristics of patients with or without HGM. HGM (+) Esophagus (n = 51)
Duodenum (n = 35)
HGM (–) (n = 6716)
Total (n = 6802)
Scand J Gastroenterol Downloaded from informahealthcare.com by University of Nebraska on 11/06/14 For personal use only.
Male 30 (58.8%) 22 (62.9%) 3557 (53.0%) 3614 (53.1%) Female 21 (41.2%)* 13 (37.1%)* 3159 (47.0%) 3193 (46.9%) Mean 43.6 ± 12.8# 41.3 ± 11.4# 44.5 ± 13.5 44.3 ± 12.8 age (years) HGM(+): Patients with HGM; HGM(–): Patients without HGM. * p < 0.01 patients with HGM (+) vs. patients without HGM (–). # p > 0.05 patients with HGM (+) vs. patients without HGM (–).
12.8 years in patients with esophageal HGM, 41.3 ± 11.4 years in patients with duodenal HGM, and 44.5 ± 13.5 years in patients without HGM (n = 6716), respectively (both p > 0.05) (Table I). During the study period, HGM was not diagnosed in all the 3504 patients who underwent colonoscopy. Endoscopic features Esophageal HGM. In patients with HGM of esophageal origin, HGM appeared as a round or oval salmon-colored patch and was located distal to upper esophageal sphincter (16–22 cm from the frontal incisor teeth). Twenty-eight patients (54.9%) had one patch, and 23 patients (45.1%) had two or more patches. Mean greatest diameter of HGM was 2–20 mm. No ulcer, bleeding, or stricture was found to be associated with HGM. Neutral beam injection imaging of an esophageal HGM patch is presented in Figure 2. Duodenal HGM. In patients with HGM of duodenal origin, HGM was appeared as a hemispherical solitary polyp (
