Clinical significance of heterotopic gastric mucosal patch of the proximal esophagus

Table 1 Clinico-pathological classification for heterotopic gastric mucosa of the proximal esophagus

Category	Description	Symptoms/findings
I	Asymptomatic	None
II	Symptomatic	Laryngopharyngeal reflux
III	Symptomatic with benign complications	Strictures/webs/fistula/bleeding
IV	Intra-epithelial dysplasia	None/non-specific
V	Malignant transformation	Asymptomatic/dysphagia

Table 2 Prevalence of symptoms reported to be associated with heterotopic gastric mucosa of the proximal esophagus in adult

Ref.	Symptoms reported	Prevalence of LPR symptoms		P value
		HGMPE (+ve)	HGMPE (-ve)
Chong et al[8]	Overall LPR symptoms	73.1%	25.9%	< 0.001
	Chronic cough	29.2%	10.6%	< 0.01
	Sore throat/hoarseness	54.2%	11.7%	< 0.01
	Globus	23.1%	7.1%	< 0.01
	Regurgitation	42.3%	13.1%	< 0.01
	Heartburn	50.0%	22.5%	< 0.01
Akbayir et al[15]	Upper esophageal and laryngopharyngeal symptoms	45%	21.5%	= 0.07
Baudet et al[21]	Dysphagia	21%	4.0%	< 0.001
Poyrazoglu et al[22]	Dysphagia	39.4%	0%	< 0.05
Alagozlu et al[23]	Globus	78.6%	0%	< 0.05
	Dyspepsia	88.2%	97.8%	NS
1Neumann et al[24]	Dysphagia/odynophagia	20.8%	16.4%	< 0.001
	Upper respiratory symptoms	2.5%	0.9%	< 0.001
	Globus	1.6%	0.3%	< 0.001
Weickert et al[25]	Recurrent hoarseness	9.1%	5.6%	= 0.5
	Dysphagia (any grade upper and lower)	15.2%	9.4%	NS
	Heartburn (any grade upper and lower)	15.2%	9.4%	NS

¹In the study by Neumann et al, the symptoms presented are symptom recorded as indications for endoscopy. HGMPE: Heterotopic gastric mucosa of the proximal esophagus; LPR: Laryngopharyngeal reflux; NS: Not significant.

Table 3 Endoscopic studies reporting the associations between heterotopic gastric mucosa of the proximal esophagus and other endoscopic findings with special attention to Barrett’s esophagus n (%)

Ref.	Prevalence of HGMPE	Findings
Positive association
Avidan et al[4]	53 (1.1)	Significantly more reflux esophagitis (77 vs 50, P = 0.023), Barrett’s esophagus (34 vs 9, P < 0.001), hiatus hernia (49 vs 30, P < 0.05) and gastric ulcer (P < 0.05) On multivariate analysis, hiatus hernia, gastric ulcer and Barrett’s esophagus remained significant
Alagozlu et al[23]	68 (1)	Significantly more (P < 0.05) endoscopic Barrett’s esophagus in patients with HGM (13.2 vs 2.4) but not with reflux esophagitis (10.3 vs 9.5) Hiatus hernia and duodenal ulcer were reported in 13.2% and 10.3% respectively but no comparisons were made
1Neumann et al[24]	870 (0.18)	Significantly more Barrett’s mucosa on biopsy (9.7 vs 6.5, P < 0.001), adenocarcinoma arising from Barrett’s mucosa (3.6 vs 0.7, P < 0.01) and reflux esophagitis (41.8 vs 49.7, P < 0.001)
Yuksel et al[27]	171 (1.8)	Significantly more reflux esophagitis (25.1 vs 5.6, P < 0.001) and histologically proven Barrett’s esophagus (3.5 vs 0.5, P < 0.000) No difference in hiatus hernia
No association
Borhan-Monesh et al[3]	64 (10)	No significant difference (all P = NS) between reflux esophagitis (34.3 vs 38.1) and Barrett’s esophagus
Chong et al[8]	26 (5.6)	No significant difference (all P = NS) between esophageal, gastric and duodenal findings including Barrett’s esophagus (3.8 vs 3.7), hiatus hernia (15.4 vs 12.2) and ulcers
Akbayir et al[15]	11 (1.67)	No significant difference (all P = NS): Barrett’s esophagus (0 vs 0.9), hiatus hernia (0 vs 10), reflux esophagitis (27 vs 16) and duodenal ulcer (9 vs 7)
2Poyrazoglu et al[22]	33 (3.6)	No significant difference (all P = NS): Barrett’s esophagus (0 vs 0.8), hiatus hernia (3 vs 9.1), reflux esophagitis (36.4 vs 34.8), gastric ulcer (3 vs 3) and duodenal ulcer (6.1 vs 6.8)
Weickert et al[25]	33 (11)	Overall prevalence: hiatus hernia (n = 92, 30.7%), reflux esophagitis (n = 41, 13.7%), Barrett’s esophagus (n = 3, 1%), gastric ulcer (n = 24, 8%) and duodenal ulcer (n = 22, 7%), all P = NS
Jacobs et al[28]	33 (4.9)	Significant difference for reflux esophagitis (27.3 vs 11.4) but not for hiatus hernia (15.2 vs 12.5), Barrett’s esophagus (6.1 vs 1.1) and any gastric or duodenal ulcer (15.2 vs 6.1)

Studies included are those with more than 10 patients with heterotopic gastric mucosa of the proximal esophagus (HGMPE).

¹The study by Neumann et al was based on analysis clinic-pathologic records of patients who had undergone upper gastrointestinal endoscopy with biopsies between January 2008 and December 2010 in private outpatient clinics and endoscopy centres in the United States;

²The study by Poyrazoglu et al compared the prevalence of other endoscopic findings between 33 patients with HGMPE with 132 matched controls without HGMPE. NS: Not significant.

Table 4 Complications of heterotopic gastric mucosa of the proximal esophagus reported in the literature

Clinico-pathological classification	Conditions	Status	Numbers based on PubMed literature search
Type III	Stricture	Reported	6
	Web	Reported	4
	Bleeding	Reported	1
	Fistula	Reported	4
	Perforation	Reported	2
	Polyp1	Reported	4
Type IV2	Dysplasia
	Low grade	Reported	None
	High grade	Reported	3[32-34]
Type V2	Adenocarcinoma
	Early (pT1 tumor)	Reported	13[35-48]
	Advanced	Reported	19[33,49-54]

References for type III cases reported in the literature not included in the reference list.

¹Not included in the original classification proposed by von Rahden et al[1];

²Number of cases of neoplastic transformation identified through literature searches up till December 2011.