These are the NBI images of a young woman complaining of chest pain, dysphagia and reflux symptoms. She also complains of feeling of a 'lump at the back of her throat'.
WHAT WAS THE ORIGINAL DIAGNOSIS?
■ Reflux oesophagitis
Would be an odd pattern surely?
■ Barrett's oesophagus
With squamous mucosa below?
■ Eosinophilic oesophagitis
EoE doesn't look brown on NBI !
■ Oesophageal inlet patch
Yes, but why is it getting smaller?
■ Squamous dysplasia
No dilated IPCL's !!!
This patient was found to have a large oesophageal inlet patch at the index endoscopy a year ago. Although his symptoms were rather mixed, we have spent 4 sessions on ablating her inlet patch with APC.
Of course, how often you find these will depend on whether you use NBI/FICE/BLE during extubation. Of course you should do because you are then less likely to miss squamous dysplasia!
An interesting study reported that gastric inlet patches contained glucagon cells which would normally only be found in the embryo and subsequently disappear. To remind you, the hormone glucagon is normally produced by the alpha cells of the pancreas! Glucagon-like peptide-1 is also secreted by some cells in the ileum and colon. Anyway, the implication is that the gastric inlet mucosa is actually an embryonic left-over. Interestingly, there appears to be a lower prevalence reported in older populations, and some authors suggest that inlet patches may regress with age! Seems odd for a congenital condition?
Endoscopic studies have found inlet patches in up to 10% of patients. Whether these give rise to any symptoms is contentious. It has been suggested that inlet patches may give rise to globus sensation due to irritation of the upper oesophageal sphincter by acid or mucus. Furthermore, others have suggested that H. pylori colonization of the heterotopic gastric mucosa causes symptoms. Others believe that it's not just the upper oesophageal sphincter which is abnormal but the entire oesophageal motility may be disorganised in these patients.
However, prospective studies have usually not found that patients in whom an inlet patch is found, present with any different symptoms compared to patient without an inlet patch.
Of course as anywhere in the body, cancer may develop. A study in Digestive Diseases & Sciences [2018;63(2):452-65] reported on 156,236 gastroscopies and may have found 3 cases of malignant conversion. Assuming that 10% of their patients had an inlet patch, that would suggest that you would have to regularly surveil 500 patients with an inlet patch over many years detect 1 cancer. If you grab 500 random people off a street and scope them annually for 5 years, wouldn't you pick up more than a single early oesophageal cancer? Seems like that lemon is not worth the squeeze?
Finally, how about our patient? Over the period of one year, we spent about one hour ablating and completely getting rid of that large inlet patch (well two inlet patches really). The patient reported that symptoms were much better for a couple of months but then returned as before. Of course as she no longer has an inlet patch, we can now conclude that it never did contribute to her symptoms. Must admit that I was sceptical from the start! Show me a prospective RCT with evidence that ablation provides a clinically significant improvement in patients globus symptoms for more than a few months!
Until I see that RCT, I will not be offering ablation for these patients.