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The role of endoscopy with combined chromoscopy in the diagnosis of Barrett's esophagus

N.V. Korochanskaya1,2, V.M. Durleshter1,2, S.A. Gabriel2, R.M. Tlekhurai2, V.V. Ryabchun2, N.E. Shabanova2, T.M. Semenikhina3, S.S. Khusainova2
1 - Department of Surgery No. 1 of Faculty of Pedagogical Training and Teaching Staff of KSMU, Russia, 350008, Krasnodar, st. Gray hair 4;
2 - MUZ city hospital No. 2 “KMLDO”, Russia, 350012, Krasnodar, st. Red Partisans, 6/2;
3 - emergency hospital medical care, Russia, 350042, Krasnodar, st. 40th anniversary of the Victory, 14. E-mail: [email protected]

The article presents our own data from an endoscopic examination of patients with a long history of gastroesophageal reflux disease and the presence of Barrett's esophagus (BE). To clarify the diagnosis of BE, combined chromoscopy was used according to the original method. It has been demonstrated that endoscopy is the main method for diagnosing BE (sensitivity - from 85 to 90%), allowing to obtain material for histological examination. The use of intravital staining with vital dyes of the esophageal mucosa improves the quality of diagnosis of this disease.

Keywords: gastroesophageal reflux disease, Barrett's esophagus, esophageal adenocarcinoma, endoscopy with chromoscopy.

Over the past 20 years, a significant increase in esophageal adenocarcinoma (AEC) has been observed in the Russian Federation and throughout the world. About 95% of cases of ACP are registered in patients with BE. The frequency of its development in such patients increases to 800 cases per 100,000 population per year. BE is a serious complication of gastroesophageal reflux disease (GERD), characterized by the replacement of squamous epithelium with columnar epithelium in the form of specialized intestinal metaplasia within the esophagus. BE is considered by the world community of gastroenterologists as a precancerous condition.

Modern endoscopic technologies facilitate the diagnosis of Barrett's esophagus. These include: fluorescent endoscopy, NBI technologies - with high resolution and magnification; ultrasound endoscopic examination. Great progress in endoscopy has been the creation of a technique using vital dyes (methylene blue, Lugol's solution, Congo red, indigo carmine), which are used for more accurate diagnosis of early forms of cancer and precancerous diseases, studying the topography of functional and organic lesions, and monitoring the effectiveness of treatment.

Goal of the work- evaluate the value of combined chromoscopy in the diagnosis of BE.

Materials and methods

The results of a survey of 97 patients who were treated at the Municipal Hospital No. 2 KMLDO from 2007 to 2009 and who had a history of GERD lasting more than 5 years are summarized. Of these, 41 were women and 56 men aged from 18 to 70 years. All patients underwent a complex of diagnostic studies, including: standard endoscopy (video information system with a digital image analyzer from Olympus Evis Exera GIF-150, Japan) with chromoscopy and subsequent biopsy of the mucous membrane (MU) of the esophagus, polypositional X-ray examination, daily pH monitoring using the Gastroscan 24 device (Istok-Sistema, Fryazino) using standard probes with 3 antimony electrodes and a cutaneous silver chloride reference electrode. In our work, we were the first to use combined chromoscopy (priority certificate No. 2009120040 dated May 26, 2009) with Lugol's solutions 1% and methylene blue 1% during endoscopy in order to improve the visualization of pathological changes in CO. Lugol's solution was applied first, the unchanged epithelium acquired a dark brown color, and the edges of the affected esophageal mucus were clearly visualized. The second dye was methylene blue. Foci of metaplasia were painted in a dark blue-brown color, and unchanged SM acquired a light blue-brown color. After combined staining, areas of the mucosa with uneven edges like flames, usually not rising above the surface, were visualized; a biopsy was taken from the areas marked during chromoscopy for morphological verification of the diagnosis. We assessed the boundaries and extent of foci of columnar cell metaplasia of the distal esophagus based on the Prague criteria developed by the International Working Group of Experts on the Classification of Esophagitis at the 12th European Gastroenterological Week in 2004. All patients received conservative therapy with proton pump inhibitors in average therapeutic doses (omeprazole or its analogues 40 mg per day - 4 weeks for non-erosive GERD, 8 weeks for erosive-ulcerative form, then maintenance therapy 20 mg per day), course admission for 3 weeks prokinetics (domperidone 30-40 mg per day), as well as antacids on demand. 2 months after drug treatment, patients with BE had an endoscopic examination with combined chromoscopy and biopsy repeated.

Results and discussion

According to the morphological study, the presence of metaplasia was confirmed in 21 patients, which amounted to 21.6% of the total number of examined GERD patients.

Of these, 6 women and 15 men aged from 18 to 70 years. The results of pathohistological examination of OM are presented in Table 1.

Table 1. Morphological changes in the esophageal mucosa in patients with Barrett's esophagus (n=21)

Figure 1 shows the native picture of BE: a bright red area of ​​the mucosa is visualized at the level of the Z-line.

Rice. 1. FGDS. A bright red area of ​​the mucosa is visualized at the level of the Z-line

We identified the following types of BE extent: ultrashort segment up to 1 cm - 8 cases, of which one was gastric, five were gastrointestinal and two were intestinal metaplasias; short segments from 1 to 3 cm - 11, respectively, of which 4 are gastric, 4 are gastrointestinal and 3 are intestinal metaplasias; two long segments with gastric metaplasia.

Due to the lack of a reference method, it is impossible to calculate the sensitivity and specificity of our proposed method for diagnosing BE.

Against the background of conservative therapy, a reverse development of inflammatory changes in the esophagus was noted, while the foci of metaplasia remained unchanged, which influenced the improvement in the quality of detection of BE. Carrying out combined chromoscopy after drug treatment made it possible to perform a more qualitative biopsy with subsequent morphological verification of the diagnosis. All patients with BE continued treatment with proton pump inhibitors at maintenance doses.

Combined chromoscopy is presented in Figure 2; the focus of metaplasia and its boundaries are visualized more clearly.

Rice. 2. Combined chromoscopy with Lugol's solution and methylene blue. An area of ​​stained mucosa with increased relief

Daily pH measurements are presented in Table 2. The average pH value was slightly below normal due to the presence of pathological reflux. In patients with BE, % of total time with pH<4 практически в 1,5 раза превосходил нормы. Число продолжительных рефлюксов больше 5 мин и индекс De Meester были выше нормы. Время наибольшей продолжительности рефлюкса почти в два раза выше нормальных значений.

Table 2. Indicators of daily pH-metry in patients with GERD complicated by Barrett's esophagus

Note: the norm is cited from A. A. Ilchenko and E. Ya. Selezneva, 2001.

The use of combined chromoscopy during endoscopic examination makes it possible to identify the boundaries of foci of metaplasia for targeted biopsy with subsequent morphological verification of the diagnosis. Carrying out conservative therapy in patients with a long history of GERD contributes to the disappearance of inflammatory changes of an erosive nature, but at the same time, foci of metaplasia of the mucosa are more clearly visualized during repeated endoscopies, which improves the quality of chromoscopy with subsequent biopsy.

LITERATURE

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3. Ivashkin V. T., Trukhmanov A. S. Program treatment of gastroesophageal reflux disease in the daily practice of a doctor // Russian Journal of Gastroenterology, Hepatology, Coloproctology. - 2003.- No. 6. - P. 18-26.

4. Kashin S.V., Ivannikov I.O. Barrett’s esophagus: principles of endoscopic diagnosis and drug therapy // Russian Journal of Gastroenterology, Hepatology, Coloproctology. - 2006. - T. XVI. No. 6. - pp. 73-78.

5. Savelyev V. S., Isakov Yu. F., Lopatkin N. A. et al. Guide to clinical endoscopy / Ed. V. S. Savelyev, V. M. Buyanova, G. I. Lukomsky - M.: Medicine. -1985. - P. 544.

6. Falk G. W. Gastroesophageal refux disease and Barrett's esophagus // Endoscopy. - 2001. - Vol. 33. No. 2. - P. 109-118.

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