2014-04-24 18:51:27 UTC

Emerging Barrett’s Esophagus in Asia

May 1, 2014


Akiko Shiotani, MD, PhD

Internal Medicine Kawasaki Medical School


Ken Haruma, MD, PhD

Internal Medicine Kawasaki Medical School

Experts shed light on differing diagnosis criteria and prevalence across the world.

Definition and Diagnosis
A widely accepted definition of Barrett’s esophagus (BE) requires the endoscopic appearance of a columnar-lined esophagus (CLE) and an esophageal biopsy demonstrating specialized intestinal metaplasia (SIM), which is known to predispose to the development of dysplasia and esophageal adenocarcinoma (EAC). However, in the U.K. and Japan, BE is defined simply as CLE, and SIM is not required for the diagnosis. Moreover, most Western studies use the proximal margin of the longitudinal gastric folds as the landmark to determine the esophago-gastric junction (EGJ) (as defined by the Prague C and M criteria), while many Japanese and some Korean studies use the distal margin of the palisade vessels for determination of the EGJ. Ultra-short segment BE (< 1 cm), a common form of BE described in Asia, is not considered BE at all by the latest British definition. These different criteria for identifying the EGJ and for defining BE endoscopically and histologically may account for some of the disparities among Western and Asian countries in studies on BE.

A number of endoscopic methods, including chromoendoscopy, have been used for the optical detection of SIM. Magnification endoscopy with narrow-band imaging (ME-NBI), which provides better detail of the mucosal and vascular patterns of minute lesions, has been reported to be helpful in identifying SIM and dysplasia in BE. Several classification systems have been developed for BE evaluation using ME-NBI, and we recently reported detection of an intestinal phenotype (with expression of intestinal markers such as CDX2 and MUC2) in 95 percent of CLE with a tubular/villous pattern observed by ME-NBI.1

The reported prevalence of BE in patients with gastroesophageal reflux disease (GERD) is higher than in the general population. The reported prevalence of short segment BE (SSBE) and long segment BE (LSBE) in Western countries ranges from 1.1 to 17.2 percent and 0.5 to 7.2 percent, respectively, while those prevalences in Asia range from 0.04 to 20 percent and 0.01 to 6.6 percent.2 The LSBE prevalence in Asia is still extremely low and less than 1 percent in most reports, although the prevalence of BE is increasing. In reports from Japan, the highest rates of BE described are 19.9 percent for histologic BE and 43 percent for endoscopic BE, which is almost exclusively SSBE. This high incidence of SSBE may be due not only to differences in BE criteria used, heightened endoscopists’ awareness of BE and increased availability of NBI, but also due to the reduction of H. pylori infection.

Barrett’s EAC
Since 1975, the incidence of EAC in the U.S. has increased by more than 500 percent. Unlike the clear-cut rising incidence of EAC in the West, the incidence trend in Asia is less clear. In Singapore, there has been a large increase in EAC and a relative decrease in squamous cell carcinoma, while the incidence of both cancers in Japan remains relatively unchanged. Moreover, the incidence of EAC is declining in Hong Kong, but remains unchanged in Taiwan and Korea.

Risk Factors for BE
Male gender, advancing age, hiatal hernia, as well as lifestyle and diet-related factors such as visceral obesity, metabolic syndrome, meat, tobacco and alcohol consumption have been reported to be risk factors for BE and EAC. In contrast, H. pylori infection and fruit and vegetable intake appear to be protective factors. H. pylori infection is reported to be relatively infrequent in patients with BE, especially LSBE. Pangastritis and corpus gastritis with decreased acid production caused by H. pylori infection has been proposed as the protective factor in BE.

Some studies suggest that genetic factors might account for the significant inter-racial differences in the incidence of BE and EAC. In both the U.K. and U.S., studies have shown a higher incidence of BE and EAC in Caucasians as compared to Black and non-Asian ethnicities (OR 3.55, 95 percent C.I. 1.85-6.85). In the multi-racial Malaysian population, the incidence of BE is significantly higher in Indians than in Malays and Chinese. Rajendra et al.3 have described an association of GERD and BE with the HLA-B07 gene, which is common in both Caucasians and Indians, but not in East and Southeast Asians.

The natural history of SSBE is not fully understood, and the factors associated with its elongation of the columnar metaplasia are also unclear. In most cases, BE is thought to reach its maximum length when it first develops, with little subsequent change over time. In an earlier study from our group, the cumulative incidence of elongation of SSBE was 3.3 percent over a follow-up period of five years, and risk factors for elongation were the absence of atrophic gastritis, the presence of reflux esophagitis and flame-shaped SSBE.4

Drs. Shiotani and Haruma have no conflicts to disclose.


1. Murao T, Shiotani A, Yamanaka Y, et al. Usefulness of endoscopic brushing and magnified endoscopy with narrow band imaging (ME-NBI) to detect intestinal phenotype in columnar-lined esophagus. J Gastroenterol 2012;47:1108-14.

2. Chang CY, Cook MB, Lee YC, et al. Current status of Barrett’s esophagus research in Asia. J Gastroenterol Hepatol 2011;26:240-6.

3. Rajendra S. Barrett’s oesophagus in Asians--are ethnic differences due to genes or the environment? J Intern Med 2011;270:421-7.

4. Manabe N, Haruma K, Imamura H, et al. Does short-segment columnar-lined esophagus elongate during a mean follow-up period of 5.7 years? Dig Endosc 2011;23:166-72.

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