**12. Overview**

Endoscopy is important part of our armamentarium for the evaluation of suspected gastrointestinal pathologies. Significant pathologies commonly encountered in the upper gastrointestinal tract include gastro-esophageal reflux related disorders (esophagitis, ulcers and strictures), varices, esophageal tumor, gastric ulcers, gastric tumor and duodenal ulcers. Most clinicians and endoscopists are aware of these pathologies. The proximal esophagus is frequently neglected during endoscopy with little time spent to examine this area. Pathologies found in or around the proximal esophagus include HGMP/CIP, Zenker's diverticulum, esophageal web, downhill varices and venous blebs or hematoma.

HGMP/CIP is an interesting clinical entity that still hold many mysteries and is still relatively under-recognized and unknown to many clinicians, even those who manage patients with laryngopharyngeal reflux disorders. It was first reported by Schmidt in 1805 (Schidmt, 1805). There are still very few publications compared to other esophageal disorders and only in the last decade the number of publications on this entity has increased, albeit slightly.

The proximal location of the HGMP/CIP contributes to the low detection as this area is difficult to examine. Endoscopists need to be aware and look for this condition. Studies have

Second, the actual incidence of HGMP/CIP is not exactly known. Earlier endoscopic studies have reported rates ranging from 0.35 to 10.0% and a latest study that had used NBI reported a rate of 13.8% (Ohara, 2010). An autopsy studies have reported rate as high as 70%. However, autopsy studies on paediatric population in the mid-twentieth century had only reported rates of less than 10%. With the advent of newer imaging modalities that provide superior endoscopic images, this will provide more accurate incidence. The true incidence rates are likely to be close to the rates reported by NBI studies given the clear distinction of HGMP/CIP observed with NBI. In future studies, it is very important that the endoscopists are aware and to look for this lesions. Several studies have already reported that the pick up rates were higher when endoscopist were aware of the entity (Maconi et al.,

The third controversy relates the clinical significance of HGMP/CIP in clinical practice. While many have found low prevalence of symptoms in associated with HGMP/CIP, it is no doubt that HGMP/CIP have clinical significance given the reported complications that

Other controversies include suggested association with extra-esophageal cancers in the aerodigestive tract. Incidence of laryngeal carcinoma has been shown to be higher in patients

HGMP/CIP remains a mysterious entity that have not been well studied compared to other esophageal disorders. Encouragingly, in the last decade, the number of publications on HGMP/CIP has been increasing. However most of these studies have only looked at the clinical and histological profiles without further addressing newer areas that can help to address the controversies that still surround HGMP/CIP. Future areas of interest include addressing the controversies that still surround HGMP/CIP. Other areas of interest are

Endoscopy is important part of our armamentarium for the evaluation of suspected gastrointestinal pathologies. Significant pathologies commonly encountered in the upper gastrointestinal tract include gastro-esophageal reflux related disorders (esophagitis, ulcers and strictures), varices, esophageal tumor, gastric ulcers, gastric tumor and duodenal ulcers. Most clinicians and endoscopists are aware of these pathologies. The proximal esophagus is frequently neglected during endoscopy with little time spent to examine this area. Pathologies found in or around the proximal esophagus include HGMP/CIP, Zenker's

HGMP/CIP is an interesting clinical entity that still hold many mysteries and is still relatively under-recognized and unknown to many clinicians, even those who manage patients with laryngopharyngeal reflux disorders. It was first reported by Schmidt in 1805 (Schidmt, 1805). There are still very few publications compared to other esophageal disorders and only in the last decade the number of publications on this entity has increased, albeit

The proximal location of the HGMP/CIP contributes to the low detection as this area is difficult to examine. Endoscopists need to be aware and look for this condition. Studies have

diverticulum, esophageal web, downhill varices and venous blebs or hematoma.

with laryngopharyngeal reflux disorder (Copper MP et al., 2000).

2000; Azar et al., 2007).

**11. Future areas** 

highlighted in Table 4.

**12. Overview** 

slightly.

include malignant transformations.

shown higher pick up rate when the lesions are being looked for. HGMP/CIP can also be found in the other part of the esophagus. On endoscopy, HGMP/CIP appears as a salmoncolored or velvety patch on white light endoscopy that is distinct from the esophageal squamous mucosa. HGMP/CIP may appear different color on other imaging techniques. Use of confocal endoscopy has been reported for the diagnosis of HGMP/CIP (López-Cerón Pinilla M et al., 2011). Majority of HGMP/CIP are solitary but can be multiple and the sizes can range from very small to very large. In patients with multiple patches, they are usually small and are located in close proximity of each other. They are typically found on the right or left lateral esophageal wall but can also be circumferential. They are usually oval, ovoid or round but can be elongated in shape.


Table 4. Future areas to address on HGMP/CIP

HGMP/CIP is reported to cause laryngopharyngeal reflux or extra-esophageal symptoms of gastro-esophageal reflux disorder. The reported frequency of laryngopharyngeal reflux symptoms ranged from very low to as high as 75% in patients with HGMP/CIP (Chong & Jalihal, 2010). Fortunately, most laryngopharyngeal reflux symptoms are mild. However, complications such as ulcerations, strictures, perforation and malignant transformation have been reported (von Rahden et al., 2004). Associations with higher frequency of laryngopharyngeal malignancies in patients with laryngopharyngeal reflux have also been reported.

The current clinico-pathological classification proposed by von-Rahden *et al.* provides a useful classification of the various manifestations of HGMP/CIP (von Rahden et al., 2004). It also guides clinical management which largely depends on the presence and severity of symptoms. Management is mainly with pharmacotherapy and instrumentations (endoscopic) and surgery may be required for complicated cases. Ablative therapies with argon plasma coagulation have been reported to provide symptoms relieve or cure in those with globus

Heterotopic Gastric Mucosal Patch of the Proximal Esophagus 143

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#### **13. References**


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**11** 

**Endoscopic Detection and Eradication** 

*Biophotonics Unit (Cranfield Health), Gloucestershire Hospitals NHS Foundation Trust,* 

Over the past four decades the incidence of oesophageal cancer has increased more rapidly than that of any other solid tumour in the Western World. This rise reflects the emergence of oesophageal adenocarcinoma as the most common pathological type. Despite this growing incidence, progress towards early detection and treatment has been slow and mortality figures have remained dismal – Cancer Research UK quotes overall one and five year survival rates of just 28% and 8% respectively.(CrUK, 2010) As a result, oesophageal cancer repreasents a real and growing public health problem and urgent action is required to

Most oesophageal adenocarcinoma develops following a well recognised series of cellular changes secondary to a multifactorial aetiology. In the classically described pathway there is initially a metaplastic change in the epithelial lining of the oesophagus (Barrett's oesophagus) which then progresses to 'low-grade' and then 'high-grade' dysplasia. As many as 30% of patients newly diagnosed with high-grade dysplasia may already have a coexistent invasive cancer, and between 5-60% of patients will develop cancer during

To date there is no early diagnostic test which can enable instantaneous accurate diagnosis of dysplasia. Clinicians are advised to take random biopsies from areas of Barrett's oesophagus in order to identify dysplasia, but even histological assessment of dysplasia is subjective and can be unreliable. As a result, significant dysplastic change (or even intramucosal cancer) may be missed. In addition, as dysplasia (the premalignant lesion) is difficult to identify, screening for early oesophageal cancer / high-grade dysplasia cannot currently be recommended, and as a consequence, oesophageal tumours present late and so

The early recognition of high-grade dysplasia is paramount to enabling a successful treatment strategy. Surgery is one option for patients with confimred HGD, however the emergence of multiple endotherapies over the past 20 years have demonstrated the ability to cure focal high-grade dysplasia, thus preventing progression to invasive malignancy. In this chapter we will discuss the accuracy of endoscopic and histological diagnosis of dysplasia and will consider novel endoscopic adjuncts which may improve endoscopic sensitivity. We will then discuss the endoscopic therapeutic options that are available for management of dysplastic Barrett's oesophagus and will propose a endotherapy algorithm for use in

improve detection and facilitate early intervention, ideally at a pre-malignant stage.

**1. Introduction** 

surveillance over 1-7 years.

have a poor prognosis.

specialist Barrett's surveillance centres.

**of Dysplastic Barrett's Oesophagus** 

L. Max Almond and Hugh Barr

*United Kingdom* 

