对所有中心型肥胖者筛查Barrett食管？

芝加哥– 根据一项以人群为基础的研究结果，有或无胃食管反流（GERD）症状个体的糜烂性食管炎和Barrett食管患病率相似。

Barrett食管是食管腺癌的一种前驱病变和主要风险因素，在美国和其他发达国家，食管腺癌的发病率正在以惊人的速度增加。因此，迫切需要改良对食管腺癌的筛查方法，明尼苏达州罗彻斯特市Mayo诊所的Nicholas R. Crews医生指出。

Dr. Nicholas R. Crews

Crews医生在年度消化道疾病周会议上展示的这项研究中，参与者为明尼苏达州Olmsted县50岁以上无内镜操作史居民的一个代表性样本，这些参与者随机使用以下三种方法接受Barrett食管筛查：在GI手术室的镇静内镜检查、门诊的非镇静经鼻内镜检查或在Mayo移动研究车中接受非镇静经鼻内镜检查。参与者平均年龄为70岁，其中46%为男性，209例参与者中206例为白种人，仅1/3的受试者有GERD症状。

结果发现，有GERD 症状和无GERD 症状组A-C级食管炎的患病率分别为32%和29%。相似的，在有GERD 症状和无GERD 症状的受试者中，Barret食管的检出率分别为8.7%和7.9%。每组中均有1.4%的患者表现不典型增生。有GERD症状的受试者中，Barrett食管节段的平均长度为2.4 cm，与无症状患者无显著差异。证实3个风险因素为有统计学意义的食管损伤（定义为食管炎或Barrett食管）预测因子，分别为：男性、根据腰臀比>0.9定义的中心型肥胖和每日消耗两种以上含酒精饮料。年龄、吸烟状态和体重指数均无预测意义。在接受筛查的受试者中，无食管炎或Barrett食管、有阳性内镜结果并有GERD症状以及有内镜阳性结果但无GERD症状的受试者的平均腰臀比分别为0.89、0.91和0.95。

研究结论为，男性、腰臀比>0.9定义的中心型肥胖和每日消耗两种以上含酒精饮料是包括食管炎和Barrett食管的食管损伤的预测因子。该研究直接挑战了明确的以GERD为基础的Barrett食管筛查模式，并强烈支持将有或无GERD症状的中心型肥胖白种男性作为Barrett食管的一个筛查标准。

Crews医生披露无相关利益冲突。

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By: BRUCE JANCIN, Internal Medicine News Digital Network

CHICAGO – The prevalence of erosive esophagitis and Barrett’s esophagus is comparable in individuals regardless of whether they have gastroesophageal reflux symptoms, according to a population-based study.

"These results directly challenge the established GERD-based Barrett’s esophagus screening paradigm and provide strong rationale for using central obesity in Caucasian males with or without symptomatic GERD as criteria for Barrett’s esophagus screening," Dr. Nicholas R. Crews said at the annual Digestive Disease Week.

"In this study, waist-hip ratio was our surrogate marker for central obesity. It’s easily obtainable and usable in clinical practice," noted Dr. Crews of the Mayo Clinic in Rochester, Minn.

Barrett’s esophagus is the precursor lesion and principal risk factor for esophageal adenocarcinoma, a malignancy whose incidence in the United States and other developed nations is increasing at an alarming rate. Improved methods of screening for esophageal adenocarcinoma are sorely needed, he added.

Dr. Crews presented a study in which a representative sample of Olmsted County, Minn., residents over age 50 with no history of endoscopy were randomized to screening for Barrett’s esophagus by one of three methods: sedated endoscopy in the GI suite, unsedated transnasal endoscopy in the clinic, or unsedated transnasal endoscopy in a Mayo mobile research van.

Participants’ mean age was 70 years, 46% were men, 206 of the 209 were white, and only one-third of subjects had GERD symptoms.

The prevalence of esophagitis grades A-C proved to be 32% in the symptomatic GERD group and similar at 29% in those without GERD symptoms. Similarly, Barrett’s esophagus was identified in 8.7% of the symptomatic GERD group and 7.9% of subjects without GERD symptoms. Dysplasia was present in 1.4% of each group. The mean length of the esophageal segment with Barrett’s esophagus was 2.4 cm in patients with GERD symptoms and not significantly different in those who were asymptomatic.

Three risk factors proved significant as predictors of esophageal injury as defined by esophagitis or Barrett’s esophagus: male sex, central obesity as defined by a waist-hip ratio greater than 0.9, and consumption of more than two alcoholic drinks per day. Age, smoking status, and body mass index were not predictive.

The mean waist-to-hip ratio was 0.89 in screened subjects with no esophagitis or Barrett’s esophagus, 0.91 in those with positive endoscopic findings and symptomatic gastroesophageal reflux, and 0.95 in those with positive findings who were asymptomatic.

Audience members expressed skepticism about the notion of routinely screening for Barrett’s esophagus in individuals with central obesity in an era of an unprecedented obesity epidemic.

For example, Dr. Joel E. Richter, who described himself as "an anti-Barrett’s person," commented that he believes gastroenterologists are already overdiagnosing and overtreating the condition, needlessly alarming many patients.

In women, particularly, it’s increasingly clear that Barrett’s esophagus only rarely develops into esophageal adenocarcinoma, he said.

"Others have said that women with Barrett’s esophagus are as likely to get esophageal cancer as men are to get breast cancer," commented Dr. Richter, professor of internal medicine and director of the center for swallowing disorders at the University of South Florida, Tampa.

Another audience member told Dr. Crews, "I totally agree with you that we miss most people with Barrett’s by our current screening process. The problem is, it’s unclear whether it’s important or not to find them. To extrapolate from your study and say that anyone with central obesity ought to be screened for [Barrett’s esophagus] is a little strong, I think."

"It’s very controversial," Dr. Crews agreed. "It’s something we continue to struggle with."

He reported having no relevant financial conflicts.