BACKGROUND Barrett’s esophagus(BE),which has increased in prevalence worldwide,is a precursor for esophageal adenocarcinoma.Although there is a gap in the detection rates between endoscopic BE and histological BE in ...BACKGROUND Barrett’s esophagus(BE),which has increased in prevalence worldwide,is a precursor for esophageal adenocarcinoma.Although there is a gap in the detection rates between endoscopic BE and histological BE in current research,we trained our artificial intelligence(AI)system with images of endoscopic BE and tested the system with images of histological BE.AIM To assess whether an AI system can aid in the detection of BE in our setting.METHODS Endoscopic narrow-band imaging(NBI)was collected from Chung Shan Medical University Hospital and Changhua Christian Hospital,resulting in 724 cases,with 86 patients having pathological results.Three senior endoscopists,who were instructing physicians of the Digestive Endoscopy Society of Taiwan,independently annotated the images in the development set to determine whether each image was classified as an endoscopic BE.The test set consisted of 160 endoscopic images of 86 cases with histological results.RESULTS Six pre-trained models were compared,and EfficientNetV2B2(accuracy[ACC]:0.8)was selected as the backbone architecture for further evaluation due to better ACC results.In the final test,the AI system correctly identified 66 of 70 cases of BE and 85 of 90 cases without BE,resulting in an ACC of 94.37%.CONCLUSION Our AI system,which was trained by NBI of endoscopic BE,can adequately predict endoscopic images of histological BE.The ACC,sensitivity,and specificity are 94.37%,94.29%,and 94.44%,respectively.展开更多
BACKGROUND Esophageal replacement(ER)with gastric pull-up(GPU)or jejunal interposition(JI)used to be the standard treatment for long-gap esophageal atresia(LGEA).Changes of the ER grafts on a macro-and microscopic lev...BACKGROUND Esophageal replacement(ER)with gastric pull-up(GPU)or jejunal interposition(JI)used to be the standard treatment for long-gap esophageal atresia(LGEA).Changes of the ER grafts on a macro-and microscopic level however,are unknown.AIM To evaluate long-term clinical symptoms and anatomical and mucosal changes in adolescents and adults after ER for LGEA.METHODS A cohort study was conducted including all LGEA patients≥16 years who had undergone GPU or JI between 1985-2003 at two tertiary referral centers in the Netherlands.Patients underwent clinical assessment,contrast study and endoscopy with biopsy.Data was collected prospectively.Group differences between JI and GPU patients,and associations between different outcome measures were assessed using the Fisher’s exact test for bivariate variables and the Mann-Whitney U-test for continuous variables.Differences with a P-value<0.05 were considered statistically significant.RESULTS Nine GPU patients and eleven JI patients were included.Median age at follow-up was 21.5 years and 24.4 years,respectively.Reflux was reported in six GPU patients(67%)vs four JI patients(36%)(P=0.37).Dysphagia symptoms were reported in 64%of JI patients,compared to 22%of GPU patients(P=0.09).Contrast studies showed dilatation of the jejunal graft in six patients(55%)and graft lengthening in four of these six patients.Endoscopy revealed columnar-lined esophagus in three GPU patients(33%)and intestinal metaplasia was histologically confirmed in two patients(22%).No association was found between reflux symptoms and macroscopic anomalies or intestinal metaplasia.Three GPU patients(33%)experienced severe feeding problems vs none in the JI group.The median body mass index of JI patients was 20.9 kg/m^(2) vs 19.5 kg/m^(2) in GPU patients(P=0.08).CONCLUSION The majority of GPU patients had reflux and intestinal metaplasia in 22%.The majority of JI patients had dysphagia and a dilated graft.Follow-up after ER for LGEA is essential.展开更多
The application of artificial intelligence(AI)in gastrointestinal endoscopy has gained significant traction over the last decade.One of the more recent applications of AI in this field includes the detection of dyspla...The application of artificial intelligence(AI)in gastrointestinal endoscopy has gained significant traction over the last decade.One of the more recent applications of AI in this field includes the detection of dysplasia and cancer in Barrett’s esophagus(BE).AI using deep learning methods has shown promise as an adjunct to the endoscopist in detecting dysplasia and cancer.Apart from visual detection and diagnosis,AI may also aid in reducing the considerable interobserver variability in identifying and distinguishing dysplasia on whole slide images from digitized BE histology slides.This review aims to provide a comprehensive summary of the key studies thus far as well as providing an insight into the future role of AI in Barrett’s esophagus.展开更多
Barrett's esophagus is a premalignant condition caused by gastroesophageal reflux. Once developed, it can progress through varying grades of dysplasia to esoph-ageal adenocarcinoma. Whilst it is well accepted that...Barrett's esophagus is a premalignant condition caused by gastroesophageal reflux. Once developed, it can progress through varying grades of dysplasia to esoph-ageal adenocarcinoma. Whilst it is well accepted that Barrett's esophagus is caused by gastroesophageal reflux, the molecular mechanisms of its pathogenesis and progression to cancer remain unclear. MicroRNAs (miRNAs) are short segments of RNA that have been shown to control the expression of many human genes. They have been implicated in most cellular processes, and the role of miRNAs in disease development is be-coming increasingly evident. Understanding altered miRNA expression is likely to help unravel the molecular mechanisms that underpin the development of Barrett's esophagus and its progression to cancer.展开更多
Barrett’s esophagus(BE)is a condition that results from replacement of the damaged normal squamous esophageal mucosa to intestinal columnar mucosa and is the most significant predisposing factor for development of es...Barrett’s esophagus(BE)is a condition that results from replacement of the damaged normal squamous esophageal mucosa to intestinal columnar mucosa and is the most significant predisposing factor for development of esophageal adenocarcinoma.Current guidelines recommend endoscopic evaluation for screening and surveillance based on various risk factors which has limitations such as invasiveness,availability of a trained specialist,patient logistics and cost.Trans-nasal endoscopy is a less invasive modality but still has similar limitations such as limited availability of trained specialist and costs.Non-endoscopic modalities,in comparison,require minimal intervention,can be done in an office visit and has the potential to be a more ideal choice for mass public screening and surveillance,particularly in patents at low risk for BE.These include newer generations of esophageal capsule endoscopy which provides direct visualization of BE,and tethered capsule endomicroscopy which can obtain high-resolution images of the esophagus.Various cell collection devices coupled with biomarkers have been used for BE screening.Cytosponge,in combination with TFF3,as well as EsophaCap and EsoCheck have shown promising results in various studies when used with various biomarkers.Other modalities including circulatory microRNAs and volatile organic compounds that have demonstrated favorable outcomes.Use of these cell collection methods for BE surveillance is a potential area of future research.展开更多
Objective To investigate the efficacy and safety of the second-generation argon plasma coagulation (VIO APC) in ablation of Barrett’s esophagus. Methods Eighteen patients with Barrett’s esophagus (12 males, median a...Objective To investigate the efficacy and safety of the second-generation argon plasma coagulation (VIO APC) in ablation of Barrett’s esophagus. Methods Eighteen patients with Barrett’s esophagus (12 males, median age of 55 years, median length of 2.1 cm,1 low-grade dysplasia, 13 cases of short segment Barrett’s esophagus) received VIO APC, which was performed at a power setting of 40W and argon gas flow at 1.5-2.0 L/min, "forced" mode, in 1-3 sessions (mean 1.3). All the patients received treatment with high-dose proton pump inhibitors. The main complaints before ablation were upper abdominal pain in 12 patients (66%), sour regurgitation in 14 patients (77%), and dysphagia or odynophagia in 7 patients (38%). Two patients (11%) had esophageal hiatal hernia. Results The percentage of patients in whom ablation was endoscopically achieved proximal to the gastroesophageal junction was 77.8% (14/18), and histologically achieved in 66.7% (12/18). Berried glands were observed in 2 patients who had achieved endoscopic ablation, the areas of Barrett’s mucosa were reduced by more than 60% in the other 4 patients. After treatment, 4 patients had transient retrosternal pain and 3 patients had mild epigastric discomfort. One patient had small amounts of hemorrhage during the process, and it ceased after norepinephrine and thrombosin were administered through endoscope biopsy channel. No esophageal stricture or other severe adverse events was observed. During 11.8 (4-15) months’ follow-up, the patients who had achieved the complete ablation had no evidence of relapse of Barrett’s esophagus. Conclusion VIO APC with a relatively low power setting can effectively ablate the Barrett’s mucosa with special intestinal metaplasia when standard APC has been done. No severe adverse events were observed. Long-term follow-up is needed to assess cancer prevention and the durability of the neo-squamous epithelium.展开更多
Barrett's esophagus(BE)is the precursor to esophageal adenocarcinoma(EAC).Progression to cancer typically occurs in a stepwise fashion through worsening dysplasia and ultimately,invasive neoplasia.Established EAC ...Barrett's esophagus(BE)is the precursor to esophageal adenocarcinoma(EAC).Progression to cancer typically occurs in a stepwise fashion through worsening dysplasia and ultimately,invasive neoplasia.Established EAC with deep involvement of the esophageal wall and/or metastatic disease is invariably associated with poor long-term survival rates.This guides the rationale of surveillance of Barrett’s in an attempt to treat lesions at an earlier,and potentially curative stage.The last two decades have seen a paradigm shift in management of Barrett’s with rapid expansion in the role of endoscopic eradication therapy(EET)for management of dysplastic and early neoplastic BE,and there have been substantial changes to international consensus guidelines for management of early BE based on evolving evidence.This review aims to assist the physician in the therapeutic decision-making process with patients by comprehensive review and summary of literature surrounding natural history of Barrett’s by histological stage,and the effectiveness of interventions in attenuating the risk posed by its natural history.Key findings were as follows.Non-dysplastic Barrett’s is associated with extremely low risk of progression,and interventions cannot be justified.The annual risk of cancer progression in low grade dysplasia is between 1%-3%;EET can be offered though evidence for its benefit remains confined to highly select settings.High-grade dysplasia progresses to cancer in 5%-10%per year;EET is similarly effective to and less morbid than surgery and should be routinely performed for this indication.Risk of nodal metastases in intramucosal cancer is 2%-4%,which is comparable to operative mortality rate,so EET is usually preferred.Submucosal cancer is associated with nodal metastases in 14%-41%hence surgery remains standard of care,except for select situations.展开更多
BACKGROUND Barrett’s esophagus is a known complication of long-standing gastroesophageal reflux disease,and it is a potential risk factor of developing esophageal adenocarcinoma.CASE SUMMARY Here,we present a case of...BACKGROUND Barrett’s esophagus is a known complication of long-standing gastroesophageal reflux disease,and it is a potential risk factor of developing esophageal adenocarcinoma.CASE SUMMARY Here,we present a case of a 47-year-old male patient referred to the gastroenterology clinic for upper endoscopy because he has a long-standing history of heartburn and vomiting after meals.On examination,he had characteristic findings of self-induced vomiting as abrasions and callosities on the dorsum of the right hand and dental erosions.A detailed history revealed that he had 17 years of binge eating with self-induced vomiting.His upper endoscopy showed gastroesophageal reflux grade D with salmon-red mucosal projections,and the biopsy revealed intestinal mucosal metaplasia.CONCLUSION This case emphasized the importance of considering upper endoscopy screening for Barrett’s esophagus in patients with eating disorders,especially those with self-induced vomiting,as in bulimia nervosa.展开更多
AIM To determine the impact of upwards titration of proton pump inhibition(PPI) on acid reflux, symptom scores and histology, compared to clinically successful fundoplication.METHODS Two cohorts of long-segment Barret...AIM To determine the impact of upwards titration of proton pump inhibition(PPI) on acid reflux, symptom scores and histology, compared to clinically successful fundoplication.METHODS Two cohorts of long-segment Barrett's esophagus(BE) patients were studied. In group 1(n = 24), increasing doses of PPI were administered in 8-wk intervals until acid reflux normalization. At each assessment, ambulatory 24 h p H recording, endoscopy with biopsies and symptom scoring(by a gastroesophageal reflux disease health related quality of life questionnaire, GERD/HRLQ) were performed. Group 2(n = 30) consisted of patients with a previous fundoplication. RESULTS In group 1, acid reflux normalized in 23 of 24 patients, resulting in improved GERD/HRQL scores(P = 0.001), which were most pronounced after the starting dose of PPI(P < 0.001). PPI treatment reached the same level of GERD/HRQL scores as after a clinically successful fundoplication(P = 0.5). Normalization of acid reflux in both groups was associated with reduction in papillary length, basal cell layer thickness, intercellular space dilatation, and acute and chronic inflammation of squamous epithelium. CONCLUSION This study shows that acid reflux and symptom scores co-vary throughout PPI increments in long-segment BE patients, especially after the first dose of PPI, reaching the same level as after a successful fundoplication. Minor changes were found among GERD markers at the morphological level.展开更多
AIM To evaluate the efficacy and safety of liquid nitrogen cryotherapy as a primary or rescue treatment for BE,with and without dysplasia,or intramucosal adenocarcinoma (IMC).METHODS This was a retrospective,single-ce...AIM To evaluate the efficacy and safety of liquid nitrogen cryotherapy as a primary or rescue treatment for BE,with and without dysplasia,or intramucosal adenocarcinoma (IMC).METHODS This was a retrospective,single-center study carried out in a tertiary care center including 45 patients with BE who was treatment-na?ve or who had persistent intestinal metaplasia(IM),dysplasia,or IMC despite prior therapy.Barrett's mucosa was resected via EMR when clinically appropriate,then patients underwent cryotherapy until eradication or until deemed to have failed treatment.Surveillance biopsies were taken at standard intervals.RESULTS From 2010 through 2014,33 patients were studied regarding the efficacy of cryotherapy.Overall,29 patients (88%) responded to cryotherapy,with 84% having complete regression of all dysplasia and cancer.Complete eradication of cancer and dysplasia was seen in 75% of subjects with IMC; the remaining two subjects did not respond to cryotherapy.Following cryotherapy,15 patients with high-grade dysplasia (HGD) had 30% complete regression,50% IM,and 7% low-grade dysplasia (LGD); one subject had persistent HGD.Complete eradication of dysplasia occurred in all 5 patients with LGD.In 5 patients with IM,complete regression occurred in 4,and IM persisted in one.In 136 cryotherapy sessions amongst 45 patients,adverse events included chest pain (1%),stricture (4%),and one gastrointestinal bleed in a patient on dual antiplatelet therapy who had previously undergone EMR.CONCLUSION Cryotherapy is an efficacious and safe treatment modality for Barrett's esophagus with and without dysplasia or intramucosal adenocarcinoma.展开更多
Barrett’s esophagus(BE)is a well-established risk factor for esophageal adenocarcinoma.It is recommended that patients have regular endoscopic surveillance,with the ultimate goal of detecting early-stage neoplastic l...Barrett’s esophagus(BE)is a well-established risk factor for esophageal adenocarcinoma.It is recommended that patients have regular endoscopic surveillance,with the ultimate goal of detecting early-stage neoplastic lesions before they can progress to invasive carcinoma.Detection of both dysplasia or early adenocarcinoma permits curative endoscopic treatments,and with this aim,thorough endoscopic assessment is crucial and improves outcomes.The burden of missed neoplasia in BE is still far from being negligible,likely due to inappropriate endoscopic surveillance.Over the last two decades,advanced imaging techniques,moving from traditional dye-spray chromoendoscopy to more practical virtual chromoendoscopy technologies,have been introduced with the aim to enhance neoplasia detection in BE.As witnessed in other fields,artificial intelligence(AI)has revolutionized the field of diagnostic endoscopy and is set to cover a pivotal role in BE as well.The aim of this commentary is to comprehensively summarize present evidence,recent research advances,and future perspectives regarding advanced imaging technology and AI in BE;the combination of computer-aided diagnosis to a widespread adoption of advanced imaging technologies is eagerly awaited.It will also provide a useful step-by-step approach for performing high-quality endoscopy in BE,in order to increase the diagnostic yield of endoscopy in clinical practice.展开更多
Endoscopic eradication therapy(EET)has become a standard of care for treatment of dysplastic Barrett’s esophagus(BE)and early Barrett’s neoplasia.EET mainly consists of removal of any visible lesions via endoscopic ...Endoscopic eradication therapy(EET)has become a standard of care for treatment of dysplastic Barrett’s esophagus(BE)and early Barrett’s neoplasia.EET mainly consists of removal of any visible lesions via endoscopic resection and eradication of all remaining Barrett’s mucosa using endoscopic ablation.Endoscopic mucosal resection and endoscopic submucosal dissection are the two available resection techniques.After complete resection of all visible lesions,it is crucial to perform endoscopic ablation to ensure complete eradication of the remaining Barrett’s segment.Endoscopic ablation can be done either with thermal techniques,including radiofrequency ablation and argon plasma coagulation,or cryotherapy techniques.The primary end point of EET is achieving complete remission of intestinal metaplasia(CRIM)to decrease the risk of dysplastic recurrence after successful EET.After CRIM is achieved,a standardized endoscopic surveillance protocol needs to be implemented for early detection of BE recurrence.展开更多
Barrett’s esophagus(BE)is a well-established pre-malignant lesion for esophageal adenocarcinoma,a condition that carries a dismal five-year overall survival rate of less than 15%.Among several available methods to el...Barrett’s esophagus(BE)is a well-established pre-malignant lesion for esophageal adenocarcinoma,a condition that carries a dismal five-year overall survival rate of less than 15%.Among several available methods to eliminate BE,radiofrequency ablation(RFA)provides the most efficient modality,since it has been demonstrated to successfully eradicate BE with or without dysplasia with acceptable safety,efficacy and durability profiles.In conjunction with proton pump therapy,this new technology has quickly become the standard care for patients with dysplastic BE.However,several technical questions remain about how to deploy RFA therapy for maximum effectiveness and long-term favorable outcomes for all stages of the disease.These include how to select patient for therapy,what the best protocol for RFA is,when to use other modalities,such as endoscopic mucosal resection,and what should be considered for refractory BE.This review addresses these questions with the perspective of the best available evidence matched with the authors’experience with the technology.展开更多
Barrett’s esophagus(BE)develops as a consequence of chronic esophageal acid exposure,and is the major risk factor for esophageal adenocarcinoma(EAC).The practices of endoscopic screening for—and surveillance of—BE,...Barrett’s esophagus(BE)develops as a consequence of chronic esophageal acid exposure,and is the major risk factor for esophageal adenocarcinoma(EAC).The practices of endoscopic screening for—and surveillance of—BE,while widespread,have failed to reduce the incidence of EAC.The majority of EACs are diagnosed in patients without a known history of BE,and current diagnostic tools are lacking in their ability to stratify patients with BE into those at low risk and those at high risk for progression to malignancy.Nonetheless,advances in endoscopic imaging and mucosal therapeutics have provided unprecedented opportunities for intervention for BE,and have vastly altered the approach to management of BE-associated mucosal neoplasia.展开更多
Background and aims:Barrett’s esophagus(BE)and colorectal neoplasms share similar risk factors.Previous studies have shown variable prevalence of colon polyps in patients with BE.Our aims were to determine the preval...Background and aims:Barrett’s esophagus(BE)and colorectal neoplasms share similar risk factors.Previous studies have shown variable prevalence of colon polyps in patients with BE.Our aims were to determine the prevalence and incidence of colon polyps in patients with BE,compared to those without BE.Methods:In this case-control study,the study group included patients,aged 50–75 years,with biopsy-proven BE,who underwent colonoscopy at Cleveland Clinic from January 2002 to December 2011.The control group consisted of age-and sex-matched patients who underwent colonoscopy and also an endoscopy with no evidence of BE during the same time period.Exclusion criteria for both groups were family-or personal previous history of colon cancer or polyps,prior colonic resection,inflammatory bowel disease and familial polyposis syndromes.Patient demographics,comorbidities,medication use and endoscopic and colonoscopic details were collected,including biopsy results.Results:A total of 519 patients were included in the study;173 patients with BE in the study group and 346 without BE in the control group.Mean age at index colonoscopy was 618 years and 75%of patients were male.On index colonoscopy,patients with BE were more likely to have polyps than controls(45%vs 32%,respectively;P=0.003).Patients underwent between one and five colonoscopies during the follow-up.On multivariate analysis—after adjusting for age,gender and diabetes—patients with BE were 80%more likely to have any type of polyp,and 50%more likely to have adenomas found during colonoscopy.Conclusions:Patients with BE had higher prevalence and incidence of colon polyps.This has important clinical implications for screening and surveillance in BE patients.展开更多
Barrett’s esophagus(BE)is an acquired condition characterized by replacement of stratified squamous epithelium by a cancer predisposing metaplastic columnar epithelium.Endoscopy with systemic biopsy protocols plays a...Barrett’s esophagus(BE)is an acquired condition characterized by replacement of stratified squamous epithelium by a cancer predisposing metaplastic columnar epithelium.Endoscopy with systemic biopsy protocols plays a vital role in diagnosis.Technological advancements in dysplasia detection improves outcomes in surveillance and treatment of patients with BE and dysplasia.These advances in endoscopic technology radically changed the treatment for dysplastic BE and early cancer from being surgical to organ-sparing endoscopic therapy.A multimodal treatment approach combining endoscopic resection of visible and/or raised lesions with ablation techniques for flat BE mucosa,followed by long-term surveillance improves the outcomes of BE.Safe and effective endoscopic treatment can be either tissue acquiring as in endoscopic mucosal resection and endoscopic submucosal dissection or tissue ablative as with photodynamic therapy,radiofrequency ablation and cryotherapy.Debatable issues such as durability of response,recognition and management of sub-squamous BE and optimal management strategy in patients with low-grade dysplasia and non-dysplastic BE need to be studied further.Development of safer wide field resection techniques,which would effectively remove all BE and obviate the need for long-term surveillance,is another research goal.Shared decision making between the patient and physician is important while considering treatment for dysplasia in BE.展开更多
AIM: To evaluate the possible association between alcohol consumption and Barrett's esophagus(BE).METHODS: We performed a systematic literature search of multiple online electronic databases.Inclusion criteria ent...AIM: To evaluate the possible association between alcohol consumption and Barrett's esophagus(BE).METHODS: We performed a systematic literature search of multiple online electronic databases.Inclusion criteria entailed studies about alcohol and BE.Metaanalysis was conducted to evaluate odds ratio(OR) and95%CIs for the association between alcohol consumption and BE.RESULTS: Twenty studies comprising 4758 patients with BE were included in the meta-analysis.The risk of BE in patients with alcohol consumption was increasedcompared with control groups(OR = 1.01; 95%CI: 1.00-1.02),especially in case-control and cohort,European and Asian,and hospital studies,but there was a decreased risk of BE associated with alcohol consumption from American studies(OR = 0.86; 95%CI: 0.77-0.96).At the same time,there was no significant association between BE and alcohol consumption in community studies(OR = 0.97; 95%CI: 0.84-1.12) and the type of alcohol(wine,beer and liquor) studies.CONCLUSION: Our meta-analysis found that alcohol consumption was associated with an increased risk of BE,especially for European and Asian drinkers.展开更多
Barrett’s esophagus is a consequence of long standing gastro-esophageal reflux disease and predisposes to the development of esophageal adenocarcinoma. Regular surveillance endoscopies can detect curable early neopla...Barrett’s esophagus is a consequence of long standing gastro-esophageal reflux disease and predisposes to the development of esophageal adenocarcinoma. Regular surveillance endoscopies can detect curable early neoplasia in asymptomatic patients, which in turn could improve the prognosis compared to symptomatic cancer. Early neoplastic lesions, which are amenable for local therapy, could be treated endoscopically, avoiding a major surgery. However, in the absence of obvious mucosal lesions, random four quadrant biopsies are done, which is associated with significant sampling error. Newer imaging modalities, such as autofluorescence endoscopy, are helpful in detecting subtle lesions that could be examined in detail with narrow band imaging to characterize and target biopsies. This has the potential benefit of reducing the number of random biopsies with a better yield of dysplasia. Confocal endomicroscopy provides "optical biopsies" and is a valuable tool in targeting biopsies to improve dysplasia detection; however, this is technically challenging. Fuji intelligent chromoendoscopy and I-Scan are recent additions to the imaging armamentarium that have produced notable early results. While all these additional new imaging techniques are promising, a thorough examination by high resolution white light endoscopy after clearing the mucosa with mucolytics should be the minimum standard to improve dysplasia detection during Barrett’s surveillance.展开更多
Confocal laser endomicroscopy (CLE) is a new endoscopic imaging technology that allows real-time, high-resolution observation of tomographic images of mucosal cells and subcellular levels in vivo, detecting microscopi...Confocal laser endomicroscopy (CLE) is a new endoscopic imaging technology that allows real-time, high-resolution observation of tomographic images of mucosal cells and subcellular levels in vivo, detecting microscopic structural changes in mucosal morphology, and its in vivo immediate pathological diagnostic capability can avoid delays in mucosal pathological diagnosis and reduce the pain caused by repeated biopsies. CLE is known as “optical biopsy” and compared with other endoscopic techniques, it has obvious advantages. CLE systems include probe-based confocal laser endomicroscopy (pCLE) and endoscope-based confocal laser endomicroscopy (eCLE). Since 2006, CLE has been widely used for the evaluation of various lesions in the digestive system, including esophageal, gastric, and colonic neoplasia, pancreatic cysts and solid lesions, and inflammatory bowel disease. The advent of CLE has made in vivo microscopic imaging possible, which has changed the endoscopic screening and diagnosis of multiple gastrointestinal (GI) lesions. However, the value of its use in GI diseases is still controversial. In this review, we focus on the application of CLE in the field of esophageal diseases.展开更多
Genomic sequencing,bioinformatics,and initial speciation(e.g.,relative abundance)of the commensal microbiome have revolutionized the way we think about the“human”body in health and disease.The interactions between t...Genomic sequencing,bioinformatics,and initial speciation(e.g.,relative abundance)of the commensal microbiome have revolutionized the way we think about the“human”body in health and disease.The interactions between the gut bacteria and the immune system of the host play a key role in the pathogenesis of gastrointestinal diseases,including those impacting the esophagus.Although relatively stable,there are a number of factors that may disrupt the delicate balance between the luminal esophageal microbiome(EM)and the host.These changes are thought to be a product of age,diet,antibiotic and other medication use,oral hygiene,smoking,and/or expression of antibiotic products(bacteriocins)by other flora.These effects may lead to persistent dysbiosis which in turn increases the risk of local inflammation,systemic inflammation,and ultimately disease progression.Research has suggested that the etiology of gastroesophageal reflux disease-related esophagitis includes a cytokine-mediated inflammatory component and is,therefore,not merely the result of esophageal mucosal exposure to corrosives(i.e.,acid).Emerging evidence also suggests that the EM plays a major role in the pathogenesis of disease by inciting an immunogenic response which ultimately propagates the inflammatory cascade.Here,we discuss the potential role for manipulating the EM as a therapeutic option for treating the root cause of various esophageal disease rather than just providing symptomatic relief(i.e.,acid suppression).展开更多
文摘BACKGROUND Barrett’s esophagus(BE),which has increased in prevalence worldwide,is a precursor for esophageal adenocarcinoma.Although there is a gap in the detection rates between endoscopic BE and histological BE in current research,we trained our artificial intelligence(AI)system with images of endoscopic BE and tested the system with images of histological BE.AIM To assess whether an AI system can aid in the detection of BE in our setting.METHODS Endoscopic narrow-band imaging(NBI)was collected from Chung Shan Medical University Hospital and Changhua Christian Hospital,resulting in 724 cases,with 86 patients having pathological results.Three senior endoscopists,who were instructing physicians of the Digestive Endoscopy Society of Taiwan,independently annotated the images in the development set to determine whether each image was classified as an endoscopic BE.The test set consisted of 160 endoscopic images of 86 cases with histological results.RESULTS Six pre-trained models were compared,and EfficientNetV2B2(accuracy[ACC]:0.8)was selected as the backbone architecture for further evaluation due to better ACC results.In the final test,the AI system correctly identified 66 of 70 cases of BE and 85 of 90 cases without BE,resulting in an ACC of 94.37%.CONCLUSION Our AI system,which was trained by NBI of endoscopic BE,can adequately predict endoscopic images of histological BE.The ACC,sensitivity,and specificity are 94.37%,94.29%,and 94.44%,respectively.
文摘BACKGROUND Esophageal replacement(ER)with gastric pull-up(GPU)or jejunal interposition(JI)used to be the standard treatment for long-gap esophageal atresia(LGEA).Changes of the ER grafts on a macro-and microscopic level however,are unknown.AIM To evaluate long-term clinical symptoms and anatomical and mucosal changes in adolescents and adults after ER for LGEA.METHODS A cohort study was conducted including all LGEA patients≥16 years who had undergone GPU or JI between 1985-2003 at two tertiary referral centers in the Netherlands.Patients underwent clinical assessment,contrast study and endoscopy with biopsy.Data was collected prospectively.Group differences between JI and GPU patients,and associations between different outcome measures were assessed using the Fisher’s exact test for bivariate variables and the Mann-Whitney U-test for continuous variables.Differences with a P-value<0.05 were considered statistically significant.RESULTS Nine GPU patients and eleven JI patients were included.Median age at follow-up was 21.5 years and 24.4 years,respectively.Reflux was reported in six GPU patients(67%)vs four JI patients(36%)(P=0.37).Dysphagia symptoms were reported in 64%of JI patients,compared to 22%of GPU patients(P=0.09).Contrast studies showed dilatation of the jejunal graft in six patients(55%)and graft lengthening in four of these six patients.Endoscopy revealed columnar-lined esophagus in three GPU patients(33%)and intestinal metaplasia was histologically confirmed in two patients(22%).No association was found between reflux symptoms and macroscopic anomalies or intestinal metaplasia.Three GPU patients(33%)experienced severe feeding problems vs none in the JI group.The median body mass index of JI patients was 20.9 kg/m^(2) vs 19.5 kg/m^(2) in GPU patients(P=0.08).CONCLUSION The majority of GPU patients had reflux and intestinal metaplasia in 22%.The majority of JI patients had dysphagia and a dilated graft.Follow-up after ER for LGEA is essential.
文摘The application of artificial intelligence(AI)in gastrointestinal endoscopy has gained significant traction over the last decade.One of the more recent applications of AI in this field includes the detection of dysplasia and cancer in Barrett’s esophagus(BE).AI using deep learning methods has shown promise as an adjunct to the endoscopist in detecting dysplasia and cancer.Apart from visual detection and diagnosis,AI may also aid in reducing the considerable interobserver variability in identifying and distinguishing dysplasia on whole slide images from digitized BE histology slides.This review aims to provide a comprehensive summary of the key studies thus far as well as providing an insight into the future role of AI in Barrett’s esophagus.
文摘Barrett's esophagus is a premalignant condition caused by gastroesophageal reflux. Once developed, it can progress through varying grades of dysplasia to esoph-ageal adenocarcinoma. Whilst it is well accepted that Barrett's esophagus is caused by gastroesophageal reflux, the molecular mechanisms of its pathogenesis and progression to cancer remain unclear. MicroRNAs (miRNAs) are short segments of RNA that have been shown to control the expression of many human genes. They have been implicated in most cellular processes, and the role of miRNAs in disease development is be-coming increasingly evident. Understanding altered miRNA expression is likely to help unravel the molecular mechanisms that underpin the development of Barrett's esophagus and its progression to cancer.
文摘Barrett’s esophagus(BE)is a condition that results from replacement of the damaged normal squamous esophageal mucosa to intestinal columnar mucosa and is the most significant predisposing factor for development of esophageal adenocarcinoma.Current guidelines recommend endoscopic evaluation for screening and surveillance based on various risk factors which has limitations such as invasiveness,availability of a trained specialist,patient logistics and cost.Trans-nasal endoscopy is a less invasive modality but still has similar limitations such as limited availability of trained specialist and costs.Non-endoscopic modalities,in comparison,require minimal intervention,can be done in an office visit and has the potential to be a more ideal choice for mass public screening and surveillance,particularly in patents at low risk for BE.These include newer generations of esophageal capsule endoscopy which provides direct visualization of BE,and tethered capsule endomicroscopy which can obtain high-resolution images of the esophagus.Various cell collection devices coupled with biomarkers have been used for BE screening.Cytosponge,in combination with TFF3,as well as EsophaCap and EsoCheck have shown promising results in various studies when used with various biomarkers.Other modalities including circulatory microRNAs and volatile organic compounds that have demonstrated favorable outcomes.Use of these cell collection methods for BE surveillance is a potential area of future research.
文摘Objective To investigate the efficacy and safety of the second-generation argon plasma coagulation (VIO APC) in ablation of Barrett’s esophagus. Methods Eighteen patients with Barrett’s esophagus (12 males, median age of 55 years, median length of 2.1 cm,1 low-grade dysplasia, 13 cases of short segment Barrett’s esophagus) received VIO APC, which was performed at a power setting of 40W and argon gas flow at 1.5-2.0 L/min, "forced" mode, in 1-3 sessions (mean 1.3). All the patients received treatment with high-dose proton pump inhibitors. The main complaints before ablation were upper abdominal pain in 12 patients (66%), sour regurgitation in 14 patients (77%), and dysphagia or odynophagia in 7 patients (38%). Two patients (11%) had esophageal hiatal hernia. Results The percentage of patients in whom ablation was endoscopically achieved proximal to the gastroesophageal junction was 77.8% (14/18), and histologically achieved in 66.7% (12/18). Berried glands were observed in 2 patients who had achieved endoscopic ablation, the areas of Barrett’s mucosa were reduced by more than 60% in the other 4 patients. After treatment, 4 patients had transient retrosternal pain and 3 patients had mild epigastric discomfort. One patient had small amounts of hemorrhage during the process, and it ceased after norepinephrine and thrombosin were administered through endoscope biopsy channel. No esophageal stricture or other severe adverse events was observed. During 11.8 (4-15) months’ follow-up, the patients who had achieved the complete ablation had no evidence of relapse of Barrett’s esophagus. Conclusion VIO APC with a relatively low power setting can effectively ablate the Barrett’s mucosa with special intestinal metaplasia when standard APC has been done. No severe adverse events were observed. Long-term follow-up is needed to assess cancer prevention and the durability of the neo-squamous epithelium.
文摘Barrett's esophagus(BE)is the precursor to esophageal adenocarcinoma(EAC).Progression to cancer typically occurs in a stepwise fashion through worsening dysplasia and ultimately,invasive neoplasia.Established EAC with deep involvement of the esophageal wall and/or metastatic disease is invariably associated with poor long-term survival rates.This guides the rationale of surveillance of Barrett’s in an attempt to treat lesions at an earlier,and potentially curative stage.The last two decades have seen a paradigm shift in management of Barrett’s with rapid expansion in the role of endoscopic eradication therapy(EET)for management of dysplastic and early neoplastic BE,and there have been substantial changes to international consensus guidelines for management of early BE based on evolving evidence.This review aims to assist the physician in the therapeutic decision-making process with patients by comprehensive review and summary of literature surrounding natural history of Barrett’s by histological stage,and the effectiveness of interventions in attenuating the risk posed by its natural history.Key findings were as follows.Non-dysplastic Barrett’s is associated with extremely low risk of progression,and interventions cannot be justified.The annual risk of cancer progression in low grade dysplasia is between 1%-3%;EET can be offered though evidence for its benefit remains confined to highly select settings.High-grade dysplasia progresses to cancer in 5%-10%per year;EET is similarly effective to and less morbid than surgery and should be routinely performed for this indication.Risk of nodal metastases in intramucosal cancer is 2%-4%,which is comparable to operative mortality rate,so EET is usually preferred.Submucosal cancer is associated with nodal metastases in 14%-41%hence surgery remains standard of care,except for select situations.
文摘BACKGROUND Barrett’s esophagus is a known complication of long-standing gastroesophageal reflux disease,and it is a potential risk factor of developing esophageal adenocarcinoma.CASE SUMMARY Here,we present a case of a 47-year-old male patient referred to the gastroenterology clinic for upper endoscopy because he has a long-standing history of heartburn and vomiting after meals.On examination,he had characteristic findings of self-induced vomiting as abrasions and callosities on the dorsum of the right hand and dental erosions.A detailed history revealed that he had 17 years of binge eating with self-induced vomiting.His upper endoscopy showed gastroesophageal reflux grade D with salmon-red mucosal projections,and the biopsy revealed intestinal mucosal metaplasia.CONCLUSION This case emphasized the importance of considering upper endoscopy screening for Barrett’s esophagus in patients with eating disorders,especially those with self-induced vomiting,as in bulimia nervosa.
文摘AIM To determine the impact of upwards titration of proton pump inhibition(PPI) on acid reflux, symptom scores and histology, compared to clinically successful fundoplication.METHODS Two cohorts of long-segment Barrett's esophagus(BE) patients were studied. In group 1(n = 24), increasing doses of PPI were administered in 8-wk intervals until acid reflux normalization. At each assessment, ambulatory 24 h p H recording, endoscopy with biopsies and symptom scoring(by a gastroesophageal reflux disease health related quality of life questionnaire, GERD/HRLQ) were performed. Group 2(n = 30) consisted of patients with a previous fundoplication. RESULTS In group 1, acid reflux normalized in 23 of 24 patients, resulting in improved GERD/HRQL scores(P = 0.001), which were most pronounced after the starting dose of PPI(P < 0.001). PPI treatment reached the same level of GERD/HRQL scores as after a clinically successful fundoplication(P = 0.5). Normalization of acid reflux in both groups was associated with reduction in papillary length, basal cell layer thickness, intercellular space dilatation, and acute and chronic inflammation of squamous epithelium. CONCLUSION This study shows that acid reflux and symptom scores co-vary throughout PPI increments in long-segment BE patients, especially after the first dose of PPI, reaching the same level as after a successful fundoplication. Minor changes were found among GERD markers at the morphological level.
文摘AIM To evaluate the efficacy and safety of liquid nitrogen cryotherapy as a primary or rescue treatment for BE,with and without dysplasia,or intramucosal adenocarcinoma (IMC).METHODS This was a retrospective,single-center study carried out in a tertiary care center including 45 patients with BE who was treatment-na?ve or who had persistent intestinal metaplasia(IM),dysplasia,or IMC despite prior therapy.Barrett's mucosa was resected via EMR when clinically appropriate,then patients underwent cryotherapy until eradication or until deemed to have failed treatment.Surveillance biopsies were taken at standard intervals.RESULTS From 2010 through 2014,33 patients were studied regarding the efficacy of cryotherapy.Overall,29 patients (88%) responded to cryotherapy,with 84% having complete regression of all dysplasia and cancer.Complete eradication of cancer and dysplasia was seen in 75% of subjects with IMC; the remaining two subjects did not respond to cryotherapy.Following cryotherapy,15 patients with high-grade dysplasia (HGD) had 30% complete regression,50% IM,and 7% low-grade dysplasia (LGD); one subject had persistent HGD.Complete eradication of dysplasia occurred in all 5 patients with LGD.In 5 patients with IM,complete regression occurred in 4,and IM persisted in one.In 136 cryotherapy sessions amongst 45 patients,adverse events included chest pain (1%),stricture (4%),and one gastrointestinal bleed in a patient on dual antiplatelet therapy who had previously undergone EMR.CONCLUSION Cryotherapy is an efficacious and safe treatment modality for Barrett's esophagus with and without dysplasia or intramucosal adenocarcinoma.
文摘Barrett’s esophagus(BE)is a well-established risk factor for esophageal adenocarcinoma.It is recommended that patients have regular endoscopic surveillance,with the ultimate goal of detecting early-stage neoplastic lesions before they can progress to invasive carcinoma.Detection of both dysplasia or early adenocarcinoma permits curative endoscopic treatments,and with this aim,thorough endoscopic assessment is crucial and improves outcomes.The burden of missed neoplasia in BE is still far from being negligible,likely due to inappropriate endoscopic surveillance.Over the last two decades,advanced imaging techniques,moving from traditional dye-spray chromoendoscopy to more practical virtual chromoendoscopy technologies,have been introduced with the aim to enhance neoplasia detection in BE.As witnessed in other fields,artificial intelligence(AI)has revolutionized the field of diagnostic endoscopy and is set to cover a pivotal role in BE as well.The aim of this commentary is to comprehensively summarize present evidence,recent research advances,and future perspectives regarding advanced imaging technology and AI in BE;the combination of computer-aided diagnosis to a widespread adoption of advanced imaging technologies is eagerly awaited.It will also provide a useful step-by-step approach for performing high-quality endoscopy in BE,in order to increase the diagnostic yield of endoscopy in clinical practice.
文摘Endoscopic eradication therapy(EET)has become a standard of care for treatment of dysplastic Barrett’s esophagus(BE)and early Barrett’s neoplasia.EET mainly consists of removal of any visible lesions via endoscopic resection and eradication of all remaining Barrett’s mucosa using endoscopic ablation.Endoscopic mucosal resection and endoscopic submucosal dissection are the two available resection techniques.After complete resection of all visible lesions,it is crucial to perform endoscopic ablation to ensure complete eradication of the remaining Barrett’s segment.Endoscopic ablation can be done either with thermal techniques,including radiofrequency ablation and argon plasma coagulation,or cryotherapy techniques.The primary end point of EET is achieving complete remission of intestinal metaplasia(CRIM)to decrease the risk of dysplastic recurrence after successful EET.After CRIM is achieved,a standardized endoscopic surveillance protocol needs to be implemented for early detection of BE recurrence.
文摘Barrett’s esophagus(BE)is a well-established pre-malignant lesion for esophageal adenocarcinoma,a condition that carries a dismal five-year overall survival rate of less than 15%.Among several available methods to eliminate BE,radiofrequency ablation(RFA)provides the most efficient modality,since it has been demonstrated to successfully eradicate BE with or without dysplasia with acceptable safety,efficacy and durability profiles.In conjunction with proton pump therapy,this new technology has quickly become the standard care for patients with dysplastic BE.However,several technical questions remain about how to deploy RFA therapy for maximum effectiveness and long-term favorable outcomes for all stages of the disease.These include how to select patient for therapy,what the best protocol for RFA is,when to use other modalities,such as endoscopic mucosal resection,and what should be considered for refractory BE.This review addresses these questions with the perspective of the best available evidence matched with the authors’experience with the technology.
基金supported by the National Institutes of Health:grant R01CA140574 to Dr.Hur.
文摘Barrett’s esophagus(BE)develops as a consequence of chronic esophageal acid exposure,and is the major risk factor for esophageal adenocarcinoma(EAC).The practices of endoscopic screening for—and surveillance of—BE,while widespread,have failed to reduce the incidence of EAC.The majority of EACs are diagnosed in patients without a known history of BE,and current diagnostic tools are lacking in their ability to stratify patients with BE into those at low risk and those at high risk for progression to malignancy.Nonetheless,advances in endoscopic imaging and mucosal therapeutics have provided unprecedented opportunities for intervention for BE,and have vastly altered the approach to management of BE-associated mucosal neoplasia.
文摘Background and aims:Barrett’s esophagus(BE)and colorectal neoplasms share similar risk factors.Previous studies have shown variable prevalence of colon polyps in patients with BE.Our aims were to determine the prevalence and incidence of colon polyps in patients with BE,compared to those without BE.Methods:In this case-control study,the study group included patients,aged 50–75 years,with biopsy-proven BE,who underwent colonoscopy at Cleveland Clinic from January 2002 to December 2011.The control group consisted of age-and sex-matched patients who underwent colonoscopy and also an endoscopy with no evidence of BE during the same time period.Exclusion criteria for both groups were family-or personal previous history of colon cancer or polyps,prior colonic resection,inflammatory bowel disease and familial polyposis syndromes.Patient demographics,comorbidities,medication use and endoscopic and colonoscopic details were collected,including biopsy results.Results:A total of 519 patients were included in the study;173 patients with BE in the study group and 346 without BE in the control group.Mean age at index colonoscopy was 618 years and 75%of patients were male.On index colonoscopy,patients with BE were more likely to have polyps than controls(45%vs 32%,respectively;P=0.003).Patients underwent between one and five colonoscopies during the follow-up.On multivariate analysis—after adjusting for age,gender and diabetes—patients with BE were 80%more likely to have any type of polyp,and 50%more likely to have adenomas found during colonoscopy.Conclusions:Patients with BE had higher prevalence and incidence of colon polyps.This has important clinical implications for screening and surveillance in BE patients.
文摘Barrett’s esophagus(BE)is an acquired condition characterized by replacement of stratified squamous epithelium by a cancer predisposing metaplastic columnar epithelium.Endoscopy with systemic biopsy protocols plays a vital role in diagnosis.Technological advancements in dysplasia detection improves outcomes in surveillance and treatment of patients with BE and dysplasia.These advances in endoscopic technology radically changed the treatment for dysplastic BE and early cancer from being surgical to organ-sparing endoscopic therapy.A multimodal treatment approach combining endoscopic resection of visible and/or raised lesions with ablation techniques for flat BE mucosa,followed by long-term surveillance improves the outcomes of BE.Safe and effective endoscopic treatment can be either tissue acquiring as in endoscopic mucosal resection and endoscopic submucosal dissection or tissue ablative as with photodynamic therapy,radiofrequency ablation and cryotherapy.Debatable issues such as durability of response,recognition and management of sub-squamous BE and optimal management strategy in patients with low-grade dysplasia and non-dysplastic BE need to be studied further.Development of safer wide field resection techniques,which would effectively remove all BE and obviate the need for long-term surveillance,is another research goal.Shared decision making between the patient and physician is important while considering treatment for dysplasia in BE.
基金Supported by National Natural Science Foundation of China,No.81300273 and 81300130
文摘AIM: To evaluate the possible association between alcohol consumption and Barrett's esophagus(BE).METHODS: We performed a systematic literature search of multiple online electronic databases.Inclusion criteria entailed studies about alcohol and BE.Metaanalysis was conducted to evaluate odds ratio(OR) and95%CIs for the association between alcohol consumption and BE.RESULTS: Twenty studies comprising 4758 patients with BE were included in the meta-analysis.The risk of BE in patients with alcohol consumption was increasedcompared with control groups(OR = 1.01; 95%CI: 1.00-1.02),especially in case-control and cohort,European and Asian,and hospital studies,but there was a decreased risk of BE associated with alcohol consumption from American studies(OR = 0.86; 95%CI: 0.77-0.96).At the same time,there was no significant association between BE and alcohol consumption in community studies(OR = 0.97; 95%CI: 0.84-1.12) and the type of alcohol(wine,beer and liquor) studies.CONCLUSION: Our meta-analysis found that alcohol consumption was associated with an increased risk of BE,especially for European and Asian drinkers.
文摘Barrett’s esophagus is a consequence of long standing gastro-esophageal reflux disease and predisposes to the development of esophageal adenocarcinoma. Regular surveillance endoscopies can detect curable early neoplasia in asymptomatic patients, which in turn could improve the prognosis compared to symptomatic cancer. Early neoplastic lesions, which are amenable for local therapy, could be treated endoscopically, avoiding a major surgery. However, in the absence of obvious mucosal lesions, random four quadrant biopsies are done, which is associated with significant sampling error. Newer imaging modalities, such as autofluorescence endoscopy, are helpful in detecting subtle lesions that could be examined in detail with narrow band imaging to characterize and target biopsies. This has the potential benefit of reducing the number of random biopsies with a better yield of dysplasia. Confocal endomicroscopy provides "optical biopsies" and is a valuable tool in targeting biopsies to improve dysplasia detection; however, this is technically challenging. Fuji intelligent chromoendoscopy and I-Scan are recent additions to the imaging armamentarium that have produced notable early results. While all these additional new imaging techniques are promising, a thorough examination by high resolution white light endoscopy after clearing the mucosa with mucolytics should be the minimum standard to improve dysplasia detection during Barrett’s surveillance.
文摘Confocal laser endomicroscopy (CLE) is a new endoscopic imaging technology that allows real-time, high-resolution observation of tomographic images of mucosal cells and subcellular levels in vivo, detecting microscopic structural changes in mucosal morphology, and its in vivo immediate pathological diagnostic capability can avoid delays in mucosal pathological diagnosis and reduce the pain caused by repeated biopsies. CLE is known as “optical biopsy” and compared with other endoscopic techniques, it has obvious advantages. CLE systems include probe-based confocal laser endomicroscopy (pCLE) and endoscope-based confocal laser endomicroscopy (eCLE). Since 2006, CLE has been widely used for the evaluation of various lesions in the digestive system, including esophageal, gastric, and colonic neoplasia, pancreatic cysts and solid lesions, and inflammatory bowel disease. The advent of CLE has made in vivo microscopic imaging possible, which has changed the endoscopic screening and diagnosis of multiple gastrointestinal (GI) lesions. However, the value of its use in GI diseases is still controversial. In this review, we focus on the application of CLE in the field of esophageal diseases.
文摘Genomic sequencing,bioinformatics,and initial speciation(e.g.,relative abundance)of the commensal microbiome have revolutionized the way we think about the“human”body in health and disease.The interactions between the gut bacteria and the immune system of the host play a key role in the pathogenesis of gastrointestinal diseases,including those impacting the esophagus.Although relatively stable,there are a number of factors that may disrupt the delicate balance between the luminal esophageal microbiome(EM)and the host.These changes are thought to be a product of age,diet,antibiotic and other medication use,oral hygiene,smoking,and/or expression of antibiotic products(bacteriocins)by other flora.These effects may lead to persistent dysbiosis which in turn increases the risk of local inflammation,systemic inflammation,and ultimately disease progression.Research has suggested that the etiology of gastroesophageal reflux disease-related esophagitis includes a cytokine-mediated inflammatory component and is,therefore,not merely the result of esophageal mucosal exposure to corrosives(i.e.,acid).Emerging evidence also suggests that the EM plays a major role in the pathogenesis of disease by inciting an immunogenic response which ultimately propagates the inflammatory cascade.Here,we discuss the potential role for manipulating the EM as a therapeutic option for treating the root cause of various esophageal disease rather than just providing symptomatic relief(i.e.,acid suppression).
