Case Control Study
Copyright ©The Author(s) 2017. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. May 14, 2017; 23(18): 3287-3294
Published online May 14, 2017. doi: 10.3748/wjg.v23.i18.3287
Risk of progression of Barrett's esophagus in patients with cirrhosis
Tehilla Apfel, Rocio Lopez, Madhusudhan R Sanaka, Prashanthi N Thota
Tehilla Apfel, Department of General Internal Medicine, Cleveland Clinic Foundation, Cleveland, OH 44195, United States
Rocio Lopez, Department of Biostatistics, Cleveland Clinic Foundation, Cleveland, OH 44195, United States
Madhusudhan R Sanaka, Prashanthi N Thota, Department of Gastroenterology and Hepatology, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, United States
Author contributions: Apfel T collected data, drafting this manuscript; Lopez R statistical analysis; Sanaka MR designed study, revised this manuscript; Thota PN designed and supervised this study, drafting and revised of manuscript.
Institutional review board statement: The study was reviewed and approved for publication by our Institutional Reviewer.
Informed consent statement: Informed consent waived by institutional review board as it is a retrospective case control study.
Conflict-of-interest statement: All the Authors have no conflict of interest related to the manuscript.
Data sharing statement: The original anonymous dataset is available on request from the corresponding author at thotap@ccf.org.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Prashanthi N Thota, MD, FACG, Director, Esophageal Center, Department of Gastroenterology and Hepatology, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44195, United States. thotap@ccf.org
Telephone: +1-216-4440780 Fax: +1-216-445-4222
Received: January 23, 2017
Peer-review started: January 27, 2017
First decision: February 23, 2017
Revised: March 11, 2017
Accepted: April 21, 2017
Article in press: April 21, 2017
Published online: May 14, 2017
Processing time: 112 Days and 0.3 Hours
Abstract
AIM

To study Barrett’s esophagus (BE) in cirrhosis and assess progression to esophageal adenocarcinoma (EAC) compared to non-cirrhotic BE controls.

METHODS

Cirrhotic patients who were found to have endoscopic evidence of BE confirmed by the presence of intestinal metaplasia on histology from 1/1/2000 to 12/1/2015 at Cleveland Clinic were included. Cirrhotic patients were matched 1:4 to BE controls without cirrhosis. Age, gender, race, BE length, hiatal hernia size, Child-Pugh (CP) class and histological findings were recorded. Cases and controls without high-grade dysplasia (HGD)/EAC and who had follow-up endoscopies were studied for incidence of dysplasia/EAC and to assess progression rates. Univariable conditional logistic regression was done to assess differences in baseline characteristics between the two groups.

RESULTS

A total of 57 patients with cirrhosis and BE were matched with 228 controls (BE without cirrhosis). The prevalence of dysplasia in cirrhosis and controls were similar with 8.8% vs 12% with low grade dysplasia (LGD) and 12.3 % vs 19.7% with HGD or EAC (P = 0.1). In the incidence cohort of 44 patients with median follow-up time of 2.7 years [interquartile range 1.0, 4.8], there were 7 cases of LGD, 2 cases of HGD, and 2 cases of EAC. There were no differences in incidence rates of HGD/EAC in nondysplastic BE between cirrhotic cases and noncirrhotic controls (1.4 vs 1.1 per 100 person- years, P = 0.8). In LGD, cirrhotic patients were found to have higher rates of progression to HGD/EAC compared to control group though this did not reach statistical significance (13.7 vs 8.1 per 100 person- years, P = 0.51). A significant association was found between a higher CP class and neoplastic progression of BE in cirrhotic patients (HR =7.9, 95%CI: 2.0-30.9, P = 0.003).

CONCLUSION

Cirrhotics with worsening liver function are at increased risk of progression of BE. More frequent endoscopic surveillance might be warranted in such patients.

Keywords: Liver cirrhosis; Barrett’s esophagus; Dysplasia; Esophageal neoplasm; Progression

Core tip: Fifty seven cirrhotic patients with Barrett’s esophagus (BE) were compared to 228 non-cirrhotic BE controls. Nonalcoholic steatohepatitis or cardiac cirrhosis was the most common causes of cirrhosis in this group. There were no differences in incidence rates of high-grade dysplasia (HGD)/esophageal adenocarcinoma (EAC) in nondysplastic BE between cirrhotic cases and noncirrhotic controls (1.4 vs 1.1 per 100 person -years, P = 0.8). In low grade dysplasia, cirrhotic patients were found to have higher rates of progression to HGD/EAC compared to control group though this did not reach statistical significance (13.7 vs 8.1 per 100 person- years, P = 0.51). There was approximately 8 times increased risk of progression for every one point increase in Child- Pugh class.