Circular stripes were more common in Barrett’s esophagus after acetic acid staining

Barrett’s esophagus (BE) is defined as the replacement of squamous epithelium of the lower esophagus by single layer columnar epithelium [1‐4], with or without the intestinal metaplasia (IM), which may be accompanied by risk of progression to carcinoma [4‐6]. In recent years, the morbidity of esophageal squamous cell carcinoma and gastric carcinoma has been decreasing, while the incidence of esophageal adenocarcinoma is gradually increasing [5]. Therefore BE has attracted more attention as the most important precancerous lesion of esophageal adenocarcinoma.

The diagnosis of BE is disturbed by numerous factors clinically. Firstly, judgment for esophagogastric junction (EGJ) is subjective to some extent [7]. EGJ is usually defined by the top of the gastric folds, or the location of esophagus palisade blood vessel [8‐13], both of which will be influenced by respiration, the volume of gas injected, the pressure of esophagus, even the relative position of diaphragmatic hiatus [9]. Secondly, the shape of the Z-line is another disturbing factor, and the biopsy result of columnar epithelium is meaningless if the initial or correct location of Z-line is wrong. Therefore, the accurate diagnosis of BE is based on correct EGJ judgment, the initial location of the Z-line, and the biopsy result above the Z-Line.

High resolution imaging technology and magnifying endoscopy have greatly improved the observation of mucosal micro-pattern. However, chromoendoscopy is irreplaceable. The acetic acid (AA) could provide better contrast of different epithelium. It is a kind of dye that can react specifically and reversibly with the columnar cells, however the exact mechanism is unclear yet. It is speculated that reversible degeneration of cellular proteins causes aceto-whitening reaction [14]. There are studies confirming that the AA used for BE epithelial staining could identify the mucosal microstructure especially highlight dysplasia and early cancer [15‐18]. Meanwhile AA can increase the contrast between the squamous and columnar epithelium, producing white line at the junction which is coincident with Z-line in the healthy people. We have noticed that AA could produce multiple white circular lines, forming circular stripes (CS) at lower esophagus, and this feature was more common in BE patients. So a retrospective study was conducted to investigate whether the CS is a special marker for BE patients.

Because the AA could give a good enhancement on the mucosa pattern at lower esophagus, we were using AA staining as a routine procedure for gastroscopy and the CS were unexpected discovery. In this study, CS were mostly observed in the BE group. There might be three potential mechanisms underneath this phenomenon.

Firstly, the CS might be caused by columnar epithelial metaplasia following squamous epithelium retraction. The AA might emphasize the gap between columnar epithelium in different periods. It could be found that the squamous epithelium was in circular pattern near the cardia in healthy people and the CS partially crossed from columnar epithelium to squamous epithelium (Fig. 3a, b), both supporting this explanation. However, the CS were only confined at the cardia within 2 cm. The emergence of new columnar epithelium in the higher position no longer formed CS anymore and could be found in punctate, reticular or villous pattern while the previous two mainly. On the other hand, there could be absence of CS in 5 BE patients and villous or punctuate mucosa pattern were observed (Fig. 3c). Therefore, the generation of the CS cannot be fully explained only by the regression and metaplasia theory.

The second possible explanation was that the CS might be specifically performed at the EGJ region and its scope exactly represented the range of EGJ. The hypothesis, that EGJ was not a simple line, but a small portion of the lower esophagus to the cardia, was suggested by previous studies [22‐24]. The dense squamous epithelium covering the EGJ might be the reason why we could less likely observe CS in the control group. When the squamous epithelium gradually became thinner or replaced by columnar epithelium, the CS would be revealed. However, more evidence needs to be found.

Thirdly, the CS might be the result of repeated hyperplasia and substitution of the cardiac epithelium. The columnar epithelium of the cardia in BE patients might be affected by inflammation [25] or mechanical motion, which led to the edema or protein change of epithelium cell. For example, some healthy people were observed with circular appearance of the cardia in the inferior position occasionally. However, there was difference between non-metaplastic CS and metaplastic CS, that stripes in the former were flatter, while the latter were often stacked (Fig. 3d).

Based on the above assumptions, CS might help to identify the EGJ, sometimes obscure in white light images, even in magnified or NBI images. EGJ is an important marker for endoscopists to get biopsy, which is necessary for the diagnosis of BE in some guidelines, such as British Society of Gastroenterology guidelines and American Gastroenterological Association on the diagnosis of BE [1, 9]. Most studies suggested that EGJ was a marker for pointing the initial position of squamous epithelium, and further evaluating distance between the EGJ and the ascending squamo-columnar junction (SCJ) precisely [1, 9‐11, 26]. Paris Workshop showed that the EGJ was located in the abdomen, just below the diaphragmatic pinch with the upper margin of the longitudinal gastric folds coinciding with the SCJ in the normal situation. The length of the metaplastic columnar segment is the distance between the neo-formed SCJ and the anatomical EGJ [26], and the reliability of the evaluation depends on the precision of the determination of the EGJ under endoscopy [26]. Mistake in EGJ judgement has little influence on diagnosis of long-segment BE, however it would mislead the diagnosis of short or ultra-short segment BE, while the majority of the Asian BE patients are in short segment [11, 26‐31]. Ishimura showed that the prevalence of long segment BE was extremely low in East Asia, while the prevalence of short segment BE was very high only in Japan [11], which was similar to Okita K and Amano Y [30, 31]. Chang CY showed that short segment BE (75.6%, n = 31) was more prevalent than long segment BE (24.4%, n = 10) in Chinese population [28, 29]. Therefore, more effective method is needed to determine EGJ. If the CS after AA staining are related to the newly hyperplastic columnar epithelium, the length of the BE epithelium can be evaluated from distal end of CS; if CS are limited to the EGJ region, then the proximal end can be borderline for hyperplastic epithelium. Multiple biopsies may prolong the time of procedure and increase patients’ suffering, and cause too much bleeding to get the high-risk lesions [18, 32]. The CS helps to outline the target area and make emphasis on the microstructure of the surface. Meanwhile the fading effect after the AA staining can help to identify the abnormal mucosal lesions [14].

The research of the CS could also help to understand the origin and development of BE. Pathologists generally believe that the BE epithelium consists of three tissue types: [1] proximal end is intestinal epithelial cells including goblet cells, [2] in the middle, it is connection type epithelium that is cardiac mucosa without goblet cells, [3] the distal end is the basal epithelium contains both parietal cells and primary cells [33‐36]. Our study indicates that CS may be a useful marker representing the connected epithelium perfectly and furthermore pathological evidences are required to support this theory.

It is generally believed that BE is closely associated with gastroesophageal reflux disease [1]. This study showed that BE patients mainly had gastroesophageal reflux symptoms, including acid reflux or heartburn, but 59.58% of patients had no symptoms of gastroesophageal reflux, which was similar to the literature reports [37‐39]. These findings suggested that there may be other etiological factors, such as race, environment, diets, use of alcohol or smoking. Therefore, we should pay attention to the people without gastroesophageal reflux symptoms. Combined with magnifying endoscopy, Toyoda improved the mucosal microstructure classification through the study of patients with BE, including 3 types: normal pits, slit-reticular pattern, and gyrus-villous pattern. The sensitivity and specificity of gyrus-villous pattern for IM were 88.5% and 90.2%, and the overall accuracy was 90.0% [35]. In this study, we observed there was no IM in the punctate and the reticular area in the BE group, while the accuracy rate of IM was 100% in the villous area, which was consistent with Toyoda. This result suggested that AA staining combined with high resolution endoscopy could also improve the yielding of BE diagnosis without magnifying endoscopy, NBI or BLI, especially in screening.

The deficiency of this research was that the sample size was limited as a pilot study. In addition, we did not classify the different types of BE because of the small sample size. So further research is needed to explore the differences and the occurrence mechanism of different types of BE, and to explore the effectiveness of different endoscopic techniques in the diagnosis of BE epithelial range and nature.

This is the pilot study that mentions and describes CS as a special feature under high resolution endoscopy with AA staining, and CS may become an important reference in the diagnosis and treatment of BE.