Introduction

The incidence of esophageal adenocarcinoma has been increasing in Western countries, with gastroesophageal reflux (GERD) and Barrett's esophagus (BE) being important risk factos for such diagnosis. In Portugal, the current prevalence of reflux esophagitis and BE is unknown, and the aim of this study is to clarify these points.

Aims & Methods

A multicenter cross-sectional study including 13 national digestive endoscopy units, involving patients who underwent upper endoscopy from January to March 2024.

Results

6320 patients were included (57% female, mean age 58). Reflux esophagitis was identified in 1105 patients (17% of the exams, 54% male, mean age 57) (Los Angeles Grade A 10.1%; B 5.6%; C 1.1%; D 0.4%) and 46 with BE (0.7% (95%CI 0.05-1%), 67.4% male, mean age 59 years), with only 4 (0.06% of the total) having 3 cm or more of extension. The prevalence of BE was higher in the Lisbon region (1.35% vs 0.5%, p<0.05), with no difference in the prevalence of reflux esophagitis. Among patients who underwent endoscopy for GERD symptoms, 38% had erosive esophagitis (p<0.05 vs the rest of the population). Among patients with esophagitis and BE, 27% and 39%, respectively, underwent endoscopy for symptoms and/or surveillance related to GERD (vs 11.6% of the rest of the population, p<0.05), with a prevalence of BE in patients with GERD of 2.3% (95%CI 2.1-2.5%, p<0.05 vs the rest of the population). Male gender was a risk factor for grade C/D esophagitis and BE (p<0.05).

Conclusion

Erosive esophagitis is common in Portugal, particularly in patients undergoing endoscopy for GERD symptoms. However, the prevalence of BE, particularly long segment BE, remains low compared to other Western countries, despite similar values of reflux esophagitis. This trend may be reversing in Lisbon with a higher prevalence of BE. Further studies are necessary to better understand these differences.

Clinical Case Summary

A 50 year old paraplegic gentleman (secondary to a road traffic accident) with a diversion colostomy and preserved small bowel length, and a history of idiopathic cirrhosis, was admitted with a one week history of high output stoma. Initially felt to be infectious, he was resuscitated with volume and electrolyte replacement. Despite a negative infection, autoimmune and extended inflammatory screen, the high stoma output persisted between 4-6L per 24 hours. He subsequently developed circulatory failure due to volume losses and required intensive care support for fluid management, parenteral nutrition (PN) and inotropes. Serial cross sectional imaging showed oedematous jejunal and ileal bowel without evidence of vascular insufficiency.

His stoma output failed to respond to maximum doses of loperamide, octreotide, proton pump inhibitors or opiates. He was commenced on a trial of high dose steroids without any benefit. A colonoscopy showed grossly oedematous bowel, with biopsies demonstrating preserved crypt architecture on a background of significant oedema. He was PN dependant with challenging management of his fluid balance. Due to a new acute renal injury with nephrotic range proteinuria, further stains on his colonic biopsies were requested. These stained positive with congo red, showing apple green birefringence which was suggestive of a diagnosis of Amyloidosis.
Following consultation with the National Amyloidosis Referral Centre, further investigations were requested which showed an amyloid load in the spleen (SAP scan) and chronic pelvic sepsis (PET CT) likely to be driving a chronic inflammatory state. Due to the advance nature of his disease, no active treatment could be offered and the patient unfortunately passed away 8 months into their hospital admission due to multi-organ failure.
Through reporting of this case, we want to raise awareness of Amyloidosis as a rare cause of Type 2 intestinal failure.