The Prevalence of and Risk Factors for Barrett Esophagus in a Korean Population - A Nationwide Multicenter Prospective Study - J Clin Gastroenterol 2009 R2 Hongjoo Lee Prof. Jae-Young Jang

Background Barrett esophagus (BE) : Presence of columnar epithelium lining the distal esophagus, of any length, with specialized intestinal metaplasia characterized by acid mucin-containing goblet cells Prevalence in Western countries long segment Barrett esophagus : 1~2% short segment Barrett esophagus (SSBE) : 6~12% 3% to 9% to 13% of patients with reflux symptoms. Eastern Asia < Western countries Objective : prospective study : prevalence of and risk factors for BE in the general Korean population screening esophagogastroduodenoscopy (EGD)

Methods Subjects January 2006 ~ July 2006 Healthcare centers of 40 hospitals nationwide in 7 different provinces 25,536 subjects screening EGD during a routine general check-up Exclusion Criteria history of gastrointestinal surgery systemic disease requiring chronic medication (except HTN and DM) Inclusion Criteria over 16 y of age agreed to participate in this nationwide survey completion of the gastroesophageal reflux questionnaire agreed to undergo an endoscopy

Methods Gastroesophageal reflux questionnaire (14 items) 7 reflux symptoms heartburn acid regurgitation chest pain hoarseness globus sensation cough epigastric soreness 7 factors related to gastroesophageal reflux drug history comorbid disease history of H. pylori eradication alcohol consumption smoking stooping posture at work monthly income most irritating symptom grade the severity a : mild b : moderate, bothersome to everyday life c : severely disturbing work or sleeping whether they had taken H2 blockers or PPI +

Methods Esophagogastric Examination presence of endoscopic BE squamous-columnar junction length of the BE long ≥ 3.0 cm short < 3.0 cm form of the BE : ie, tongue-like projection, circumferential, island of CLE RE : according to the Los Angeles classification

Methods Pathology Examination Systematic 4-quadrant biopsy specimens at 1cm intervals from the endoscopically identified columnar (pink) mucosa contain metaplastic or intestinalized columnar epithelium with goblet cells by H-E staining and Alcian blue staining (pH 2.5) Disagreement → reexamined by both pathologists until agreement was reached

Methods Statistical Analysis Categorization Age : by 10-year age intervals. Smoking and alcohol consumption : binary variables by the current status BMI : by the cut-off points of 23 and 25 (kg/m2) blood glucose and cholesterol levels : standard clinical cut-off points Chi-square tests x2 tests Hosmer-Lemeshow goodness-of-fit test SAS statistical software(SAS Institute, Cary, NC) P value < 0.05 : statistically significant.

Results Characteristics of Participating Subjects and Endoscopic Findings 25,536 subjects men 15,180(59.45%) women 10,356(40.55%) Mean subject age : 46.7±11.1 years Males, 40~59 age group, Seoul population, higher income and education RE : 2019 subjects (7.91%) Endoscopically suspected BE(ESBE) : 864 subjects (3.4%) peptic ulcer or malignancy, male sex, ≥ 50 years of age : BE subjects>normal population ESBE 864 Biopsies 642(74.3%) BE 215(33.5%) Not 222(25.7%) Columnar epithelium 386 (90.4%) Squamous epithelium 41 (9.6%)

Results Table 1. Comparison of Normal Population and Subjects With Barrett Esophagus TABLE 1. Comparison of Normal Population and Subjects With Barrett Esophagus

Results Subgroup Analysis of BE According to the Length and Form of BE, and the Presence of RE length BE : 215 subjects with BE < 10mm : 167(77.7%) 10 to 9mm : 38 (17.7%) ≥ 20mm10 (4.6%) form of BE tongue-like projections : 159 subjects (74.0%), circumferential formation : 56 (26.0%) islands of columnar epithelium : 47 (21.9%) islands of squamous epithelium : 9 (3.7%) ≥ 2 different patterns : 56 presence or absence of RE absence of RE : 167(77.7%) Presence of RE : 48 (22.3%) : no statistically significant differences - sex ratio, age, distribution of length, and forms of BE between the 2 groups.

Results Clinical Spectrum of BE Table 2. Comparison of Reflux Symptoms Between Normal and Barrett Esophagus

Results Clinical Spectrum of BE Table 3 Comparison of Reflux Symptoms of Barrett Esophagus According to the Presence of Reflux Esophagitis

Results Risk Factors for BE Table 4. Risk Factors by Multivariate Analysis According to the Association of Reflux Esophagitis With Barrett Esophagus

Conclusions Prevalence of BE in Korean patients for a routine health check-up : 0.84% - lower than reported in Western countries Among the subjects with BE 77.7% : no endoscopic erosions 39.9% : no reflux symptoms Regular endoscopic screening with a high index of suspicion is necessary for the diagnosis of BE.