Clinical Endoscopy

The Korean Society of Gastrointestinal Endoscopy (대한소화기내시경학회)
권호 표지
DOI QR코드

DOI QR Code

Prevalence of intestinal metaplasia, dysplasia, and esophageal adenocarcinoma in patients with irregular Z-line: a systematic review and meta-analysis

  • Vishali Moond (Department of Internal Medicine, Saint Peter's University Hospital/Robert Wood Johnson Medical School) ;
  • Pradeep Yarra (Department of Gastroenterology & Hepatology, Saint Louis University) ;
  • Mannat Bhatia (Department of Internal Medicine, Saint Peter's University Hospital/Robert Wood Johnson Medical School) ;
  • Sheza Malik (Department of Internal Medicine, Reading Hospital) ;
  • Vineel Malavarappu (Carver College of Medicine, University of Iowa) ;
  • Hassam Ali (Department of Gastroenterology, Hepatology & Nutrition, ECU Health Medical Center/Brody School of Medicine) ;
  • Saurabh Chandan (Division of Gastroenterology & Hepatology, Creighton University School of Medicine) ;
  • Douglas G. Adler (Center for Advanced Therapeutic Endoscopy, Centura Health, Porter Adventist Hospital) ;
  • Babu P. Mohan (Department of Gastroenterology & Hepatology, Orlando Gastroenterology PA)
  • Received : 2024.08.04
  • Accepted : 2024.11.18
  • Published : 2025.05.30
Download PDF
⟨ Previous Next ⟩

Abstract

Background/Aims: The irregular Z-line, defined as a segment of columnar mucosa less than 1 cm in the distal esophagus, is often biopsied despite guidelines advising against it due to a low risk of progression to esophageal adenocarcinoma (EAC). However, the clinical significance of an irregular Z-line remains unclear. This meta-analysis examines the prevalence of Barrett's esophagus, dysplasia, and EAC in patients with an irregular Z-line. Methods: We searched Medline, Embase, and Scopus databases up to October 2023 for studies on the prevalence of Barrett's esophagus, dysplasia, and EAC in these patients. A random-effects model was used for meta-analysis, and heterogeneity was assessed using I2 statistics. Results: Nine studies involving 17,637 patients were analyzed. Among those with an irregular Z-line, the prevalence of intestinal metaplasia was 29.4%. In patients with intestinal metaplasia, dysplasia was found in 6.2%, low-grade dysplasia in 5.9%, high-grade dysplasia in 1.6%, and EAC in 1.5%. These rates were higher compared to those without intestinal metaplasia. Conclusions: Patients with an irregular Z-line and intestinal metaplasia may be at higher risk and could benefit from endoscopic surveillance. Further studies are needed to determine the necessity of biopsying irregular Z-lines.

Keywords

Acknowledgement

Anne Rosebrock, MLS, a Reference Librarian at the Health Sciences Library, Orlando Health, provided invaluable assistance with the literature search for this study.

References

  1. Thiruvengadam SK, Tieu AH, Luber B, et al. Risk factors for progression of Barrett's esophagus to high grade dysplasia and esophageal adenocarcinoma. Sci Rep 2020;10:4899. https://doi.org/10.1038/s41598-020-61874-7
  2. American Gastroenterological Association, Spechler SJ, Sharma P, et al. American Gastroenterological Association medical position statement on the management of Barrett's esophagus. Gastroenterology 2011;140:1084–1091. https://doi.org/10.1053/j.gastro.2011.01.030
  3. ASGE Standards of Practice Committee, Evans JA, Early DS, et al. The role of endoscopy in Barrett's esophagus and other premalignant conditions of the esophagus. Gastrointest Endosc 2012;76:1087–1094. https://doi.org/10.1016/j.gie.2012.08.004
  4. Shaheen NJ, Falk GW, Iyer PG, et al. Diagnosis and management of Barrett's esophagus: an updated ACG guideline. Am J Gastroenterol 2022;117:559–587. https://doi.org/10.14309/ajg.0000000000001680
  5. Gindea C, Birla R, Hoara P, et al. Barrett esophagus: history, definition and etiopathogeny. J Med Life 2014;7 Spec No. 3(Spec Iss 3):23–30.
  6. ASGE Standards of Practice Committee, Qumseya B, Sultan S, et al. ASGE guideline on screening and surveillance of Barrett's esophagus. Gastrointest Endosc 2019;90:335–359. https://doi.org/10.1016/j.gie.2019.05.012
  7. Whiteman DC, Appleyard M, Bahin FF, et al. Australian clinical practice guidelines for the diagnosis and management of Barrett's esophagus and early esophageal adenocarcinoma. J Gastroenterol Hepatol 2015;30:804–820. https://doi.org/10.1111/jgh.12913
  8. Dickman R, Levi Z, Vilkin A, et al. Predictors of specialized intestinal metaplasia in patients with an incidental irregular Z line. Eur J Gastroenterol Hepatol 2010;22:135–138. https://doi.org/10.1097/MEG.0b013e3283318f69
  9. Ferguson DD, DeVault KR, Wolfsen HC. Should we biopsy an irregular Z-line?: the yield of biopsy to diagnose short-segment Barrett's esophagus. Gastrointest Endosc 2004;59:P264. https://doi.org/10.1016/S0016-5107(04)01173-3
  10. Freedman BL, Bilal M, Kandasamy C, et al. Risk of dysplasia and esophageal adenocarcinoma in patients with intestinal metaplasia < 1 cm in comparison to Barrett's esophagus 1-2 cm in length. Gastrointest Endosc 2020;91:AB394–AB395.
  11. Itskoviz D, Levi Z, Boltin D, et al. Risk of neoplastic progression among patients with an irregular Z line on long-term follow-up. Dig Dis Sci 2018;63:1513–1517. https://doi.org/10.1007/s10620-018-4910-1
  12. Jung KW, Talley NJ, Romero Y, et al. Epidemiology and natural history of intestinal metaplasia of the gastroesophageal junction and Barrett's esophagus: a population-based study. Am J Gastroenterol 2011;106:1447–1456. https://doi.org/10.1038/ajg.2011.130
  13. Kaminsky TJ, Colletier K, Fang JC, et al. Excessive biopsies in patients with an irregular z line and no history of Barrett's esophagus. Gastrointest Endosc 2021;93:AB306. https://doi.org/10.1016/j.gie.2021.03.629
  14. Srinivasan S, McKinley MJ, Aravapalli A, et al. Evaluation of intestinal metaplasia and dysplasia in GERD patients with an irregular versus normal appearing Z-line by forceps biopsy and WATS3D. Am J Gastroenterol 2021;116:S175. https://doi.org/10.14309/01.ajg.0000774056.08054.dd
  15. Thota PN, Vennalaganti P, Vennelaganti S, et al. Low risk of high-grade dysplasia or esophageal adenocarcinoma among patients with Barrett's esophagus less than 1 cm (irregular Z Line) within 5 years of index endoscopy. Gastroenterology 2017;152:987-992. https://doi.org/10.1053/j.gastro.2016.12.005
  16. Wani S, Williams JL, Falk GW, et al. An analysis of the GIQuIC nationwide quality registry reveals unnecessary surveillance endoscopies in patients with normal and irregular Z-lines. Am J Gastroenterol 2020;115:1869-1878. https://doi.org/10.14309/ajg.0000000000000960
  17. Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021;372:n71, https://doi.org/10.1136/bmj.n71
  18. Stroup DF, Berlin JA, Morton SC, et al. Meta-analysis of observational studies in epidemiology: a proposal for reporting: Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group JAMA 2000;283:2008-2012. https://doi.org/10.1001/jama.283.15.2008
  19. Stang A. Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses. Eur J Epidemiol 2010;25:603-605. https://doi.org/10.1007/s10654-010-9491-z
  20. DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials 1986;7:177-188. https://doi.org/10.1016/0197-2456(86)90046-2
  21. Sweeting MJ, Sutton AJ, Lambert PC. What to add to nothing?: use and avoidance of continuity corrections in meta-analysis of sparse data. Stat Med 2004;23:1351-1375. https://doi.org/10.1002/sim.1761
  22. Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ 2003;327:557-560. https://doi.org/10.1136/bmj.327.7414.557
  23. Rothstein HR, Sutton AJ, Borenstein M. Publication bias in meta-analysis: prevention, assessment and adjustments. John Wiley & Sons; 2005.
  24. Krishnamoorthi R, Singh S, Ragunathan K, et al. Factors associated with progression of Barrett's esophagus: a systematic review and meta-analysis. Clin Gastroenterol Hepatol 2018;16:1046-1055. https://doi.org/10.1016/j.cgh.2017.11.044
  25. Bhat S, Coleman HG, Yousef F, et al. Risk of malignant progression in Barrett's esophagus patients: results from a large population-based study. J Natl Cancer Inst 2011;103:1049-1057. https://doi.org/10.1093/jnci/djr203