18.01.02 topic review Hiatal hernia Barrett's esophagus IM R3 송주혜
Endoscopic anatomy of EGJ Esophagogastric junction (EGJ) = Proximal margin of gastric folds = Distal end of palisade zone Squamocolumnar junction
Hiatal hernia
Definition 횡격막의식도열공주변취약부를통해식도위접합부또는위의일부가흉강내측으로탈장
Type of Hiatal hernia Type 1 : 활주열공탈장 (sliding hiatal hernia) - 식도열공주위에서식도를횡격막에부착시켜주는횡격막식도인대 (phrenoesophageal ligament) 가헐거워져서하부식도와위식도접합부, 위의상부일부가흉강내로미끄러져들어가는형태의탈장. van Herwaarden. Eur J Gastroenterol Hepatol 2005;16:831-835
- 전체식도열공탈장의 95% - 역류성식도염을일으키는주요원인중하나 - 악화인자 : 비만, 무거운것을드는운동, 임신, 위식도역류나식도점막의산화에의해유발되는식도의종주근육의긴장성수축
= Schatzki ring
Schatzki ring
Short Segment Hiatal Hernia(SSHH)
Type of Hiatal hernia Type 2 : 식도주위탈장 (para-esophageal hernia) - 횡격막식도인대의손상은없고, 열공자체가늘어나서그틈으로위의일부 ( 특히위분문부 ) 가흉강으로빠져들어가는형식의탈장. - GEJ 이 diaphragmatic orifice와같은 level, 즉정상높이에위치 - 매우드문형태.
Type of Hiatal hernia Type 3 : Type 1 + Type 2 (mixed) - 횡격막식도인대의손상으로위식도접합부가밀려올라가면서열공자체 가커지고이를통하여위분문부가흉강안으로빠져들어간형태
Barrett's esophagus
Definition 만성적인역류성식도염. 편평상피로된정상적인식도점막이점차탈락되고원주상피로변화, 조직학적으로특수장상피화생이증명되어야함 SCJ displaced proximal to EG junction Intestinal metaplasia positive Goblet cells
Endoscopic findings 바렛식도의가장중요한내시경소견은 EGJ 보다상방으로이동한 SCJ cf) 정상 SCJ 은분홍빛을띈회색의편평상피와연어빛붉은오렌지색인원주상피간의 색조차이로관찰됨
Length of Barrett esophagus (Prague method) M: maximum length C: circumference length 표기예 : C3M5
2015 Australian Guideline for diagnosis and management of Barrett s esophagus and early esophageal adenocarcinoma Barrett's esophagus (BE), a common condition, is the only known precursor to esophageal adenocarcinoma (EAC). There is uncertainty about the best way to manage BE, since most people with BE never develop EAC and most patients diagnosed with EAC have no preceding diagnosis of BE.
For the Australian guidelines however, the presence of intestinal metaplasia with morphologically typical goblet cells was considered necessary for the diagnosis of BE. Biopsies from the tubular esophagus containing columnar mucosa without intestinal metaplasia should be given a descriptive diagnosis (e.g. columnar mucosa without intestinal metaplasia), but it is currently recommended that these are not diagnosed as BE until the biological significance of this entity is clarified.
Random four-quadrant biopsies at 2cm intervals are the mainstay for tissue sampling. (Recommendation grade B) Symptomatic patients with BE should be treated with Proton Pump Inhibitor therapy (PPI), with the dose titrated to control symptoms. (Grade C) There is insufficient evidence to recommend the use of acid suppressive therapy for the regression of BE (Grade B).
The effect of PPIs on Barrett s esophagus
Long term outcome studies do not yet support ablation in patients without dysplasia. (Grade B) Ablation of BE should remain limited to individuals with HGD in BE who are at imminent risk of developing esophageal adenocarcinoma. (Grade B) Patients with Barrett's Esophagus length equal to or greater than 3cm may have intensive surveillance, possibly every two to three years following the Seattle protocol. (Grade D)
2016 ACG clinical guideline : Diagnosis and Management of Barrett s Esophagus Endoscopic biopsy should not be performed in the presence of a normal Z line or a Z line with < 1 cm of variability (strong recommendation, low level of evidence). patients with nondysplastic BE should undergo endoscopic surveillance no more frequently than every 3-5 years. Patients with BE should receive once-daily PPI therapy.
Surveillance biopsy 우리나라서양보다 Barrett Esophagus가드물고대부분단분절이며, Dysplasia를동반한경우는거의없음바렛식도환자의 surveillance 내시경간격은중증도보다는통상의위암검진간격으로진행 (1-2년에한번 ) 서양 Barrett esophagus가보이면조직검사를시행함서양에서의 surveillance 간격은길지만 surveillance 때에는대부분조직검사시행그러나 barrett esophagus surveillance가 outcome을개선했다는결과는없음
In practice 1 cm 미만의바렛식도가의심되면사진을잘찍어두고결과지에언급하지않는다. 임상적의의가없는소견으로간주한다. 1 cm - 3 cm의바렛식도가의심되면사진을잘찍어두고조직검사를 2개정도시행하고결과지에 r/o short segment Barrett's esophagus로쓴다. 3 cm 이상의바렛식도가의심되면사진을잘찍어두고조직검사를 4개정도시행하고결과지에 r/o long segment Barrett's esophagus로쓴다. Dysplasia가있거나의심되면전문가에게의뢰한다. Dysplasia가없으면 1년후추적내시경검사를시행한다. 추적내시경에서자세히관찰하여특별히의심되는곳이없으면조직검사를하지않아도좋다.
Reference 1. 2016 ACG clinical guideline : Diagnosis and Management of Barrett s Esophagus 2. 2015 Australian Guideline for diagnosis and management of Barrett s esophagus and early esophageal adenocarcinoma 3. 소화기내시경아틀라스 4. www.endotoday.com