Published online Jul 7, 2019. doi: 10.3748/wjg.v25.i25.3231
Peer-review started: January 8, 2019
First decision: January 30, 2019
Revised: February 24, 2019
Accepted: March 1, 2019
Article in press: March 2, 2019
Published online: July 7, 2019
Barrett’s esophagus (BE) is generally recognized as a pre-malignant condition and is associated with the development of esophageal adenocarcinoma. The presence of intestinal metaplasia (IM) is generally required for diagnosis because it is the only type of esophageal columnar epithelium that clearly predisposes individuals to cancer development. The updated guidelines of the American College of Gastroenterology recommend that BE should be diagnosed when there is extension of salmon-colored mucosa into the tubular esophagus extending ≥ 1 cm proximal to the gastroesophageal junction with biopsy confirmation of IM. The prevalence of BE in the general populations of Asian countries ranges from 0.06% to 1%, which is lower than that in western countries. However, with adoption of western customs and lifestyle changes in Asian countries, the prevalence of BE might have increased.
Currently, there is a lack of universal diagnostic criteria for BE because the definition varies among different countries and is updated as time goes by. Nevertheless, the most updated guidelines from the American College of Gastroenterology provide a pragmatic framework for our daily clinical practice. We wished to update the current prevalence of BE in Taiwan based on these criteria strictly.
To determine the current prevalence of BE in Taiwan, and to investigate risk factors predicting the presence of BE.
Subjects undergoing routine esophagogastroduodenoscopy examinations as part of a health check-up at the Health Evaluation Center of Kaohsiung Veterans General Hospital in Taiwan were included. Subjects aged below 20 years or refused biopsy examination were excluded. Endoscopic findings consistent with BE awaiting histological evaluation were judged as endoscopically suspected esophageal metaplasia (ESEM). The diagnosis of BE requires an extension of the columnar epithelium ≥ 1 cm above the gastroesophageal junction and the presence of specialized IM in the metaplastic esophageal epithelium. To determine the risk factors for BE, clinical and endoscopic parameters were examined using univariate analysis. The variables found to be statistically significant in univariate analysis were subsequently assessed using multivariate analysis to identify independent factors predicting BE. Categorical data were compared using the χ2 test or Fisher’s exact test, as appropriate. The Student’s t-test was used for the comparison of continuous data. A P value less than 0.05 was considered statistically significant.
A total of 3387 subjects were recruited in the study. Of these, two who were aged below 20 years were excluded from the study. Thus, 3385 individuals (mean age, 51.29 ± 11.42 years; 57.1% male) were included in further analyses. ESEM was found in 423 individuals, and 89 among them were confirmed to have IM and presence of goblet cells via biopsy examination. Therefore, the overall prevalence of BE was 2.6%. Factors that were significantly associated with a higher risk for BE via multivariate analysis included old age [odds ratio (OR) = 1.033; 95% confidence interval (CI): 1.012-1.055; P = 0.002], male gender (OR = 2.106; 95%CI: 1.145-3.872; P = 0.017), ingestion of tea (OR = 1.695; 95%CI: 1.043-2.754; P = 0.033), and presence of hiatal hernia (OR = 3.037; 95%CI: 1.765-5.225; P < 0.001). Old age alone was the only independent risk factor for the presence of IM in ESEM lesions (OR = 1.029; 95%CI: 1.006-1.053; P = 0.014).
The current prevalence of BE among the general population in Taiwan is 2.6%. Its prevalence in Taiwan is not only the highest in Asian countries but also comparable with that in western countries. Adoption in western customs and foods might have contributed to this phenomenon substantially. From this study, we confirmed that old age, male gender, and presence of hiatal hernia were solid risk factors for BE. Besides, ingestion of tea, a common habit of Asian people, is also significantly associated with the development of BE in Taiwan. Such a finding has been rarely reported in previous studies. The results of the present study demonstrated that old age significantly increased the likelihood of discovering IM in ESEM lesions, with a 1.029-fold increase in odds ratio per year of age increase. From this point, more attention should be paid when ESEM is observed in older individuals in clinical practice, as these lesions have a higher likelihood of bearing IM.
As this is a retrospective observational study and was subject to confounding due to other unmeasured variables, the true prevalence of BE might have been underestimated. Well-designed prospective clinical trials are needed to reveal the real prevalence of BE in the future. The exact mechanism responsible for the impact of tea ingestion on the development of BE is not clear. Further studies focusing on this topic are required.