Inflammation and intestinal metaplasia at the squamocolumnar junction in young patients with or without Helicobacter pylori infection. (Stomach).

Background: Intestinal metaplasia (IM) in the oesophagus is a known risk factor for adenocarcinoma of the oesophagus. The incidence of adenocarcinoma of the cardia and oesophagus has increased in Western countries simultaneously with a decrease in Helicobacter pylori prevalence.

Aims: To determine the association of H pylori infection with inflammation and IM at the squamo-columnar junction (SCJ) in young individuals.

Patients: A total of 168 (121 women; 72%) consecutive outpatients, [less than or equal to]45 years, undergoing gastroscopy, and with no prior H pylori eradication treatment.

Methods: Biopsy specimens taken from the antrum, corpus, SCJ, and oesophagus were assessed according to the updated Sydney system, and type of IM (complete or incomplete) was determined. Serum samples from H pylori positive patients were studied for CagA antibodies.

Results: In 86% of 37 patients with gastritis in the antrum and/or corpus (24 histologically H pylori positive) and in 23% of 125 patients with a healthy stomach, inflammation was present in the glandular mucosa at the SCJ. In the latter, cardiac mucosa more often than fundic mucosa at the SCJ was inflamed (p.<0.001), the inflammation was usually milder in nature, and was associated with signs of reflux disease. IM (incomplete or complete) at the SCJ was evident in nine of those 24 with a healthy stomach and inflamed cardiac mucosa at the SCJ but in none of those with H pylori gastritis.

Conclusions: IM at the SCJ can also appear in young individuals in whom it seems to be associated with reflux related isolated inflammation in cardiac mucosa at the SCJ but not with H pylori gastritis.

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The presence of Helicobacter pylori infection, especially that caused by a CagA positive strain, appears to be negatively associated with Barrett's oesophagus, (1) dysplasia in Barrett's oesophagus, (1 2) and adenocarcinoma of the cardia and oesophagus. (1-4) This has raised a question as to a possible causal relationship between the increase in incidence of adenocarcinoma of the cardia and oesophagus and a simultaneous decrease in H pylori prevalence in Western countries. (5)

A columnar epithelium lined tubular oesophagus 2-3 cm in length with incomplete intestinal metaplasia (IM) is a well known risk factor for adenocarcinoma of the oesophagus. This classic Barrett's oesophagus is however a relatively uncommon finding, detected in only 1-2% of patients undergoing gastroscopy. (6-8) Subsequently, only 2-6% of oesophageal adenocarcinomas have been reported to occur in patients with known Barrett's oesophagus. (9 10) In patients without classic Barrett's oesophagus, adenocarcinomas of the gastro-oesophageal junction appear to arise from foci of IM at the squamocolumnar junction (SCJ), (11) which occur in 9-36% of patients undergoing gastroscopy. (6 12-14) IM at the SCJ or in the cardia has however been shown to be associated with H pylori infection. (15 16)

If acquired, lesions at the SCJ may be related to time of exposure to possible risk factors and to patient age; early lesions may thus be assumed to be present in young individuals in particular. This makes findings in young individuals especially interesting. The present study explored the association of H pylori infection with inflammation and IM at the SCJ in young individuals.

PATIENTS AND METHODS

Consecutive Caucasian outpatients, [less than or equal to]45 years, with no prior H pylori eradication treatment undergoing gastroscopy at Herttoniemi Municipal Hospital between March 1998 and July 1999 were included, many of whom also took part in a study assessing a serological rapid test for H pylori in a basic endoscopy population. (17) The study was approved by the ethics committee of the Helsinki City Health Department.

The study population originally comprised 172 patients, [less than or equal to]45 years, referred for gastroscopy, although for four, biopsies from the columnar side of the SCJ were unavailable, excluding these patients from further analyses. Median age of the remaining 168 patients was 34 years: 36 were 18-25 years, 60 were 26-35 years, and 72 were 36-45 years; 121 (72%) were women. The indication for gastroscopy was heartburn and/or regurgitation in 65 patients, dyspepsia or upper abdominal pain in 46, suspicion of coeliac disease in 38, follow up of coeliac disease in five and of atrophic gastritis in three, and miscellaneous reasons in 11.

A routine gastroscopy was performed by one author (AO) with an Olympus GIF-Q140 videoendoscope (Olympus Finland, Helsinki, Finland). The SCJ was assessed visually. Distances were measured from the diaphragmatic hiatus and …