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Columnar lined esophagus (CLE)

Basics

Normally the Squamous epithelium covers the innermost layer ( Mucosa) of the esophagus (gullet). Reflux inflames the esophagus. As a consequence the normal Mucosa is replaced by a Mucosa, which is lined by a columnar Epithelium. This condition is termed columnar lined esophagus (CLE). Columnar lined esophagus catalogs the following types of Mucosa ( Chandrasoma classification):
cardiac Mucosa (mucus cells only), oxyntocardiac Mucosa (mixture of mucus cells and parietal cells; parietal cells are acid producing cells, normally only exist in the body of the Stomach), intestinal metaplasia (mucus cells and goblet cells; this is Barrett’s esophagus). Via Dysplasia Barrett’s esophagus may progress towards esophageal cancer (0.5% annual risk).
Multilayered Epithelium is a mixture of squamous and columnar cells.
The classification is named after the US American pathologist Para Chandrasoma (Los Angeles).

Chandrasoma

Chandrasoma classification of columnar lined esophagus (CLE). A: cardiac mucosa. B: oxynto cardiac mucosa. C: intestinal metaplasia (Barrett’s esophagus). D: the US American pathologist Prof. Para Chandrasoma, who developed the novel CLE classification.

Causes

Columnar lined esophagus (CLE) results from Reflux. Therefore causes for CLE include all factors promoting Reflux (eating behavior, life style). In addition the presence of CLE always indicates Reflux ( Reflux is the only cause for CLE development).

Reflux

Reflux causes the development of columnar lined esophagus.

Symptoms

Symptoms of columnar lined esophagus include Heartburn, acid regurgitation, cough, asthma and difficulties at swallowing. CLE also exists without Heartburn. 10% to 15% of individuals with Barrett’s esophagus do not perceive Heartburn. Up to 75% of esophageal adenocarcinomas (cancers) develop without a preceding history of Heartburn and other Reflux symptoms.

Diagnosis and tests

Diagnosis and tests for the assessment of columnar lined esophagus include Gastroscopy and the histopathology of biopsies obtained from the esophagus. The biopsies are examined by a pathologist and cataloged according to the Chandrasoma classification (cardiac Mucosa, oxyntocardiac Mucosa, intestinal metaplasia). Dysplasia is cataloged according to the Ridell classification (named after the Canadian pathologist Robert H. Riddell). Cancer is staged according to an international classification (UICC: union international contre cancer).
Endoscopcially visible CLE ( CLEV) and the dilated distal esophagus comprise the squamo oxyntic gap (see there).

Treatment of CLE

Treatment of columnar lined esophagus (CLE) depends on the tissue type. Since Barrett’s esophagus shares the same cancer risk as a polyp of the colon (0.5% annual risk!), it is eliminated with radiofrequency ablation (RFA, HALO®). Dysplasia and early cancer is removed by endoscopic mucosal resection (±radiofrequency ablation). The treatment of advanced cancer includes a tailored oncological therapy (chemo, radiation, surgery).

Prevention of CLE

Columnar lined esophagus can be prevented by life style measure, which prevent Reflux.

Self test

Reflux symptoms ( Heartburn, cough, asthma etc.) and symptom relief upon therapy with antacids or proton pump inhibitor indicate the presence of columnar lined esophagus. You are recommended to undergo Gastroscopy. The test excludes cancer risk (Barrett’s esophagus).

Expert opinion

Johannes Lenglinger (Physiologist, Vienna):

There should be no Esophageal manometry and esophageal Reflux monitoring without a prior Gastroscopy. Adequate Biopsy sampling is essential for the exclusion of cancer risk (Barrett’s esophagus). Columnar lined esophagus proofs that a person had Reflux. This means that CLE is specific for Reflux. Esophageal Reflux monitoring assesses if Reflux is the cause for the symptoms. Therefore, the work up of Reflux patients includes Gastroscopy, manometry and Reflux monitoring.

Martin Riegler (Surgeon, Vienna):

We routinely perform standardized Biopsy sampling from the esophagus using our unique protocol. CLE is the marker for Reflux. The distance between the most proximal and most distal esophageal biopsies positive for CLE define the length of the Reflux-injured segment of the esophagus: the squamo oxyntic gap. Thus CLE helps us to diagnose Reflux. Treatment targets the CLE positive segment of the esophagus.

Sebastian Schoppmann (Surgeon, Vienna):

Gastroscopy is essential in the diagnosis of Reflux. For us the columnar lined esophagus (CLE) is a marker for Reflux. The type of tissue defines absence or presence of cancer risk. If CLE contains Barrett’s esophagus (cancer risk) we recommend radiofrequency ablation (HALO®).If Reflux hurts and medical treatment does not provide adequate Heartburn relief we offer Anti reflux surgery: the Magnetic ring operation or Fundoplication. In experienced hands Anti reflux surgery is effective in more than 90% of the cases. Over time medical therapy fails in up to 50% of the cases.

Literature

  1. Chandrasoma PT. Columnar lined esophagus: what it is and what it tells us. Eur Surg 2006; 38/3: 197-209.
  2. Lenglinger J, Eisler M, Wrba F et al. Update: histopathology-based definition of Gastroesophageal reflux disease and Barrett‘s esophagus. Eur Surg 2008; 40/4: 165-75.
  3. Lenglinger J, Izay B, Eisler M et al. Barrett‘s esophagus: size of the problem and diagnostic value of a novel histopathology classification. Eur Surg 2009; 41/1: 26-39.
  4. Goldblum JR. Controversies in the diagnosis of Barrett esophagus ad Barrett-related Dysplasia. Arch Pathol Lab Med 2010; 134: 1479-84.
  5. Odze RD. What the gastroenterologist needs to know about the histology of Barrett’s esophagus. Curr Opin Gastroenterol 2011 27(4): 389-96.
  6. Chandrasoma P, Wijetunge S, DeMeester S et al. Columnar-lined esophagus without intestinal metaplasia has no proven risk of adenocarcinoma. Am J Surg Pathol 2011 (Sept 28) ahead print.
  7. Hvid-Jensen F, Pedersen L, Mohr Drewes A et al. Incidence of adenocarcinoma among patients with Barrett’s esophagus. N Engl J Med 2011; 365: 1375-83.
  8. Fleischer DE, Odze R, Overholt BF et al. The case for endoscopic treatment of non-dysplastic and low grade dysplastic Barrett‘s esophagus. Dig Dis Sci 2010; 55: 1918-31.
  9. Triadafilopoulos G. Proton pump inhibitor in Barrett‘s esophagus: pluripotent but controversial. Eur Surg 2008; 40/2: 58-65.
  10. Chandrasoma P, Wijetunge S, Ma Y, DeMeester S et al. The dilated distal esophagus: a new entity that is the pathologic basis of early Gastroesophageal reflux disease. Am J Surg Pathol 2011; 35(12): 1873-81.
  11. Chandrasoma P, Wijetunge S, DeMeester SR et al. The histologic squamo-oxyntic gap: an accurate and reproducible diagnostic marker of Gastroesophageal reflux disease. Am J Surg Pathol 2010; 34(11): 1574-81.
  12. Glickman JN, Spechler SJ, Souza RF et al. Multilayered Epithelium in mucosal Biopsy specimens from the gastroesphageal junction region is a histologic marker of Gastroesophageal reflux disease. Am J Surg Pathol 2009; 33: 818-25.
  13. Öberg S, Peters JH, DeMeester TR et al. Inflammation and specialized intestinal metaplasia of cardiac Mucosa is a manifestation of Gastroesophageal reflux disease. Ann Surg 1997 (226); 4: 522-32.
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