Can Irregular Z Line Be Cured

Paul Gonzalez
• Friday, 30 October, 2020
• 7 min read

The Line demarcates the squamocolumnar junction (SCJ), the transition from the squamous esophageal mucosa to the columnar mucosa lining the stomach, or in cases of Barrett’s esophagus, between the squamous and internalized columnar epithelium of the meta plastic segment. An irregularZline is characterized by < 1 cm columnar tongues that extend proximal to the gastroesophageal junction, a finding that has been reported in approximately 10–15% of the population undergoing upper endoscopy .

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Nevertheless, the clinical significance of this finding with respect to the risk of progression to neoplasm in patients with an irregularZline and IM is unclear . While prior guidelines are in conflict with regard to the management strategies for putative Barrett’s esophagus (BE) segments < 1 cm, the most recent American College of Gastroenterology (ACG) guidelines recommend against obtaining biopsies from an irregularZline, a recommendation made due to the poor endoscopic standardization of this finding (one endoscopic’s normal Line is another’s irregularZline), the additional costs associated with this practice, the potential for patient anxiety, and the low rates of prevalent and incident dysplasia and esophageal adenocarcinoma (EAC) found in these lesions.

Also, patients with an irregularZline who harbor IM might be enrolled in endoscopic surveillance protocols, necessitating the costs and inconvenience of recurrent surveillance endoscopy, as well as the stigma of a disease label for a potentially neoplastic condition. A prospective single-center study by Moskovitz et al. published in the current issue of Digestive Diseases and Sciences describes the risk of developing BE, dysplasia, and EAC in those with an irregularZline and IM compared to those with an irregularZline without I'm.

There were 166 patients endoscopically diagnosed with an irregularZline, defined here as variability of 5 mm of the squamocolumnar junction on index endoscopy. Of the 166 patients who underwent upper endoscopy for indications such as heartburn, dysphagia, and chest pain, 39% (n = 64) had biopsy-proven I'm.

The authors note in their conclusion that patients with an irregularZline “do not develop major BE complication in more than 5 years of follow-up.” Yet, they also suggest in their discussion that, due to the 16% incidence of BE in the IM-positive group and the two patients who developed LED, “longer follow-up studies may reveal a more malicious nature of irregularZline with intestinal metaplasia.” This study has several commendable strengths: It is prospective, with a standardized biopsy protocol with follow-up, at a median of 70 months, which is of sufficient length to enable the observation of clinically significant trends, and appropriate covariance were considered, including careful assessment of the Line.

Several shortcomings are also evident: Loss to follow-up was substantial, especially in the group with no IM, where almost half of patients did not have a repeat examination; also, given that an irregularZline is not an indication for a repeat EGD, it is unclear whether these follow-up examinations were being done as part of the study protocol, or for clinical care. If the latter is true, the results must be viewed in a somewhat different light, due to the bias inherent in the motivations influencing patients to have repeat procedures: Patients who return for ongoing HERD symptoms might be expected to have a different prevalence of BE than those who are asymptomatic.

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The results of the present study add to a sparse, confusing, and inconclusive literature on the natural history of the irregularZline (Table 1). Theta et al. performed a recent prospective multi center study of 167 patients with an irregularZline and I'm.

The presence of a hiatal hernia can not only make it more difficult to accurately differentiate between an irregularZline and short-segment BE on index endoscopic exam, but can also falsely increase the reported prevalence of I'm if biopsies were obtained from the cardiac due to sampling error. These results are similar to a previous study that reported that more than half of those with an irregularZline with I'm on index biopsy did not have I'm on follow-up examination , underscoring the problem of sampling error that is magnified in the presence of very short segments of columnar mucosa.

Even with all this confusion and potential for bias, the results from this study and the existing literature in balance show that the irregularZline is a low-risk lesion. While a four-grade classification system for assessing the Line has been previously proposed that correlated with prevalence of I'm , it has not been adopted and applied in the clinical setting.

Until such time when superior measurements of minute changes around the Line are possible or novel biomarkers are validated, endoscopies should recognize that small amounts of Barrett’s, like beauty, are in the eye of the beholder. Theta IN, Vennalaganti P, Vennelaganti S, et al. Low risk of high-grade dysplasia or esophageal adenocarcinoma among patients with Barrett’s esophagus less than 1 cm (irregular Z line) within 5 years of index endoscopy.

Hickman R, Levi Z, Villain A, Avid I, NIV Y. Predictors of specialized intestinal metaplasia in patients with an incidental irregular Z line. Significance of intestinal metaplasia in different areas of esophagus including esophagogastric junction.

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Shaheen NJ, Fall GW, Dyer PG, Gerson LB. Moskovitz D, Levi Z, Bolton D, et al. Risk of neoplastic progression among patients with an irregular Z line on long-term follow-up.

Epidemiology and natural history of intestinal metaplasia of the gastroesophageal junction and Barrett’s esophagus: a population-based study. Length of Barrett’esophagus and cancer risk: implications from a large sample of patients with early esophageal adenocarcinoma.

When I type that into google, all the results scream “BARRETT'S ESOPHAGUS” like I'm about to die from cancer. “ “My biopsy didn't reveal anything even close to Barrett's esophagus (apparently).

A lighted tube with a camera at the end (endoscope) is passed down your throat to check for signs of changing esophagus tissue. Normal esophagus tissue appears pale and glossy.

In Barrett's esophagus, the tissue appears red and velvety. The biopsied tissue can be examined to determine the degree of change.

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No dysplasia, if Barrett's esophagus is present, but no precancerous changes are found in the cells. Low-grade dysplasia, if cells show small signs of precancerous changes.

Barrett's esophagus has a distinct appearance when viewed during an endoscopy exam. The video camera detects surface abnormalities, such as acid reflux damage or the presence of a hiatal hernia or ulcers, as well as Barrett's esophagus.

Medication and lifestyle changes can ease your signs and symptoms. Surgery or endoscopy procedures to correct a hiatal hernia or to tighten the lower esophageal sphincter that controls the flow of stomach acid may be an option.

Low-grade dysplasia is considered the early stage of precancerous changes. But, given the risk of esophageal cancer, treatment may be recommended if the diagnosis is confirmed.

Radiofrequency ablation, which uses heat to remove abnormal esophagus tissue. Cryotherapy, which uses an endoscope to apply a cold liquid or gas to abnormal cells in the esophagus.

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(Source: www.ajmadison.com)

The cycle of freezing and thawing damages the abnormal cells. Laparoscopic anti-reflux surgery for HERD may involve a procedure to reinforce the lower esophageal sphincter, called Nissan fundoplication.

In this procedure, the surgeon wraps the top of the stomach around the lower esophagus after reducing the hiatal hernia, if present. This reinforces the lower esophageal sphincter, making it less likely that acid will back up in the esophagus.

High-grade dysplasia is generally thought to be a precursor to esophageal cancer. For this reason, your doctor may recommend endoscopic resection, radiofrequency ablation or cryotherapy.

Another option may be surgery, which involves removing the damaged part of your esophagus and attaching the remaining portion to your stomach. If you have treatment other than surgery to remove abnormal esophageal tissue, your doctor is likely to recommend lifelong medication to reduce acid and help your esophagus heal.

Lifestyle changes can ease symptoms of HERD, which may underlie Barrett's esophagus. Eliminating foods and drinks that trigger your heartburn, such as chocolate, coffee, alcohol and mint.

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(Source: fanboysforever.blogspot.com)

Place wooden blocks under your bed to elevate your head. Be aware of any pre-appointment restrictions, such as not eating solid food on the day before your appointment.

Write down your symptoms, including any that may seem unrelated to the reason why you scheduled the appointment. Write down your key medical information, including other conditions.

Show references Quasar B, et al. AGE guideline on screening and surveillance of Barrett's esophagus. National Institute of Diabetes and Digestive and Kidney Diseases.

National Institute of Diabetes and Digestive and Kidney Diseases. Shaheen NJ, et al. ACG Clinical Guideline: Diagnosis and management of Barrett's esophagus.

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