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Can Irregular Z-line Be Normal

author
Brent Mccoy
• Wednesday, 18 November, 2020
• 7 min read

In Barrett’s esophagus, the Z-line is displaced proximally relative to the gastroesophageal junction. Barrett's esophagus is a serious complication of gastroesophageal reflux disease, or HERD, notes WebMD.

barrett normal oesophagus landmarks figure metaplasia dysplasia epithelium
(Source: www.wjgnet.com)

Contents

Symptoms of Barrett's esophagus are similar to those of HERD and include heartburn, chronic cough, laryngitis and nausea. Both an ultrasound and a biopsy of tissue are required for a diagnosis of Barrett's esophagus.

What Does George Soros' Open Society Foundations Network Fund? Not everyone has a straight circle -- that's why it's called the z”-line, because an irregular border is normal.

Some things that can make it more abnormal could be reflux of bile or acid into the esophagus, poor esophageal squeezing, or just a normal variation. In other words, the line is sharply demarcated but wavy as it goes around the esophagus.

The Z 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 irregular line 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 .

Nevertheless, the clinical significance of this finding with respect to the risk of progression to neoplasm in patients with an irregular line 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 irregular line, a recommendation made due to the poor endoscopic standardization of this finding (one endoscopic’s normal line is another’s irregular line), 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 irregular line 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 irregular line and IM compared to those with an irregular line without I'm.

There were 166 patients endoscopically diagnosed with an irregular line, 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 irregular line “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 irregular line 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 Z 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 irregular line 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.

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

The presence of a hiatal hernia can not only make it more difficult to accurately differentiate between an irregular line 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 irregular line 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 irregular line is a low-risk lesion. While a four-grade classification system for assessing the Z 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 Z 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.

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.

I had an upper GI procedure done to day, and it has told me I have an irregular line and Gastric Mucosal abnormality. Irregular line is something that happens to majority of people who suffer from chronic acid reflux.

I’m assuming their doing the biopsy to make sure it is only acid irritation that’s causing it. This is the gastroesophageal junction, or the location where the esophagus meets the stomach.

The glistening white appearance in the foreground is the esophagus, and this is entirely normal in these patients. The esophagus meets with the stomach which is the salmon color and that also is normal.

Often when people get heartburn, we see more irregularities of the Z-line, or we see inflammation or irritation above the Z-line in the esophagus. This is simply another example of a gastroesophageal junction showing the transition from the esophagus to the stomach.

Often people are born with these webs, and when they are very tight, they can cause difficulty swallowing food. If that is the case, we can stretch them out with what we call dilators, which allows the food to pass more easily.

This is felt to be a completely benign condition, and other than being troublesome, with difficulty swallowing food, it does not cause any serious problems. This is the very bottom of the esophagus, and compared to the photograph we saw in gastroesophageal junction, this is very tightly shut; in fact, there is only a pinhole opening.

In patients with this condition, Andalusia, there is difficulty in swallowing food, and it backs up into the esophagus. We often have to operate on patients to open this area up, but there are more recent therapies one of which is shown in the next photograph.

This is the same patient in whom we saw Andalusia, but we have injected Botox, which is used for many medical and cosmetic purposes, it is in the very bottom of the esophagus where the muscle was extremely tight. This effect is temporary, but typically lasts several months and gives remarkable relief of the symptoms.

If you simply compare the opening in this patient, you can see a dramatic difference. This condition occurs when there is a lack of blood flow to the superficial cells of the colon and thus many of them die.

This is a photograph of another patient with ischemic colitis but as compared to the other photo, we can see severe redness, swelling, and almost a bluish appearance to the wall of the bowel and as opposed to being along only one wall, this is almost the entire bowel. A hiatal hernia is a portion of the stomach that has been pulled up into the chest above the breathing muscle, or the diaphragm.

There is a very tiny amount of blood around it and there is fatty tissue, which is starting to extrude from the biopsy site. The biopsy was completely benign, and confirmed that this was, in fact, a large lipoma.

We used the device, which applies current to the area, to coagulate it, and we can see that there is virtually no bleeding at this point in time. The white that we see in the photograph is where the tissues have been coagulated or burnt, to stop the bleeding.

You can also see that at the end of the probe, or the straight gold object that is coming out of the endoscope, there appears to be a needle. Once this area was coagulated using heat, which was applied to this probe, I extended a needle out and pierced the tissue with this.

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