Diagnostic Atlas of Gastroesophageal Reflux Disease A New Histology based Method 1st Edition by Parakrama Chandrasoma 0123736056 9780123736055

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ISBN 10: 0123736056

ISBN 13: 9780123736055

Author: Parakrama T. Chandrasoma

Gastroesophageal reflux is one of the most common maladies of mankind. Approximately 40% of the adult population of the USA suffers from significant heartburn and the numerous antacids advertised incessantly on national television represents a $8 billion per year drug market. The ability to control acid secretion with the increasingly effective acid-suppressive agents such as the H2 blockers (pepcid, zantac) and proton pump inhibitors (nexium, prevacid) has given physicians an excellent method of treating the symptoms of acid reflux.

Unfortunately, this has not eradicated reflux disease. It has just changed its nature. While heartburn, ulceration and strictures have become rare, reflux-induced adenocarcinoma of the esophagus is becoming increasingly common. Adenocarcinoma of the esophagus and gastric cardia is now the most rapidly increasing cancer type in the Western world.

At present, there is no histologic test that has any practical value in the diagnosis of reflux disease. The only histologic diagnostic criteria are related to changes in the squamous epithelium which are too insensitive and nonspecific for effective patient management. It is widely recognized that columnar metaplasia of the esophagus (manifest histologically as cardiac, oxyntocardiac and intestinal epithelia) is caused by reflux. However, except for intestinal metaplasia, which is diagnostic for Barrett esophagus, these columnar epithelia are not used to diagnose reflux disease in biopsies. The reason for this is that these epithelial types are indistinguishable from “normal” “gastric” cardiac mucosa. In standard histology texts, this “normal gastric cardia” is 2-3 cm long.

In the mid-1990s, Dr. Chandrasoma and his team at USC produced autopsy data suggesting that cardiac and oxyntocardiac mucosa is normally absent from this region and that their presence in biopsies was histologic evidence of reflux disease. From this data, they determined that the presence of cardiac mucosa was a pathologic entity caused by reflux and could therefore be used as a highly specific and sensitive diagnostic criterion for the histologic diagnosis of reflux disease. They call this entity “reflux carditis”. In addition, the length of these metaplastic columnar epithelia in the esophagus was an accurate measure of the severity of reflux disease in a given patient.

At present, there is some controversy over whether cardiac mucosa is totally absent or present normally to the extent of 0-4 mm. While this should not be a deterrent to changing criteria which are dependent on there normally being 20-30 cm of cardiac mucosa, there has been little mainstream attempt to change existing endoscopic and pathologic diagnostic criteria in the mainstream of either gastroenterology or pathology.

The ATLAS will be the source of easily digestible practical information for pathologists faced with biopsies from this region. It will also guide gastroenterologists as they biopsy these patients.

* The American Gastroenterological Association claims there are 14,500 members worldwide who are practicing physicians and scientists who research, diagnose and treat disorders of the gastrointestinal tract and liver
* According to the American Society for Clinical Pathology, there are 12,000 board certified pathologists in the U.S.
* Adenocarcinoma of the esophagus and gastric cardia is now the most rapidly increasing cancer type in the Western world
* Approximately 40% of the adult population of the U.S. suffers from significant heartburn and the numerous antacids advertised on national television represents an $8 billion per year drug market

Diagnostic Atlas of Gastroesophageal Reflux Disease A New Histology based Method 1st Table of contents:

CHAPTER 1: Reflux-Induced Cancer: An Epidemic We Need to Address Now

Epidemiology of Reflux-Induced Cancer

The Problem

The Reflux-to-Adenocarcinoma Sequence

The Future Without Change

Can Reflux-Induced Adenocarcinoma Be Prevented?

Objections to Anti-Reflux Surgery

A Plea for an Aggressive Approach

Expectation of Change

REFERENCES

CHAPTER 2: The Present State of Diagnosis of Reflux Disease

Presently Used Diagnostic Criteria of Reflux Disease

Columnar-Lined Esophagus: An Inexplicably Ignored Diagnostic Criterion for Reflux Disease

REFERENCES

CHAPTER 3: Histologic Definition and Diagnosis of Epithelial Types in the Esophagus and Stomach

The Importance of Histology in Understanding Disease

Embryologic Development

Histologic Definition of Epithelial Types in Postnatal Esophagus and Proximal Stomach

Diagnosis of Columnar Epithelial Types

CASE STUDY

Application of Histologic Definitions

Problems in Differential Diagnosis Between Columnar Epithelial Types

CASE STUDY

CASE STUDY

REFERENCES

CHAPTER 4: Definition of Normal and Reflux-Induced Anatomy and Histology

Normal Anatomy

Normal Histology of the Esophagus and Proximal Stomach

Definition of the Gastroesophageal Junction

Pathogenesis of Reflux Disease

The Mechanism of Gastroesophageal Reflux

Anatomic Location and Significance of Epithelial Types: Resolution of Controversy

New Definitions of the Normal State and Gastroesophageal Reflux Disease

REFERENCES

CHAPTER 5: Cellular Changes of Non-Neoplastic Gastroesophageal Reflux Disease

Squamous Epithelial Injury

Sequence of Columnar Metaplasia of the Esophagus

Distribution of Columnar Epithelial Types

Relationship Between Prevalence of Intestinal Metaplasia and Length of Columnar-Lined Esophagus

Historical Differences in Epithelial Composition of Columnar-Lined Esophagus

Mechanism of the Genetic Switches in Columnar-Lined Esophagus

CASE STUDY

Reversibility of Genetic Switches

Barrett Esophagus: Five Decades of Medical Failure

REFERENCES

CHAPTER 6: Reflux-Induced Adenocarcinoma of the Esophagus

CASE STUDY

The Target Cell

The Carcinogen

CASE STUDY

Interaction Between Carcinogens and Target Cells

CASE STUDY

Factors Associated with an Increased Cancer Risk in Gastroesophageal Reflux Disease

Factors that Are Protective Against Development of Cancer in Barrett Esophagus

Assessment of Cancer Risk in Barrett Esophagus

Prevalent Cancer in Barrett Esophagus

Conclusion

REFERENCES

CHAPTER 7: New Histology-Based Definitions and Method of Diagnosis of Reflux Disease

A New Histologic Definition of Gastroesophageal Reflux Disease

Reflux Carditis: The Perfect Definition of Gastroesophageal Reflux Disease

A New Definition of Barrett Esophagus

CASE STUDY

A New Diagnostic Method for Reflux Disease

CASE STUDY

CASE STUDY

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