Barrett’s Esophagus – Still Uncommon in Patients with Refractory Reflux Symptoms in India!

Dear Editor, Previous Indian studies have reported the prevalence of Barrett's esophagus (BE) to be between 2.38% and 23%.[1-3] However, data on the prevalence of erosive reflux disease (ERD) and BE from Central India are lacking. Thus, the present study was done to determine the prevalence of ERD, hiatus hernia, and BE in patients with typical reflux symptoms. For this retrospective study, consecutive adult patients who underwent endoscopic evaluation for refractory reflux symptoms of >3 months duration between July 2022 and July 2023 formed the study cohort. Refractory reflux symptoms were defined as persistent symptoms despite the use of proton-pump inhibitors in at least once daily dosage for >8 weeks.[4] All patients were off proton-pump inhibitors for 2 weeks before endoscopic evaluation, and informed consent for endoscopy was taken. We excluded patients with associated dyspepsia, foregut surgery, eosinophilic esophagitis, and motility disorders. Endoscopic severity of reflux was noted as per Los Angeles classification.[5] White light endoscopy was done and enhanced mucosal imaging techniques like narrow band imaging were not used. Grading of BE was done as per Prague Classification and confirmed by histopathology.[6,7] ERD was diagnosed in patients with reflux esophagitis grades B, C, and D. Reflux esophagitis Los Angeles Class- A is a nonspecific finding and was taken as normal endoscopy finding. Endoscopic hiatus hernia was diagnosed when the apparent separation between the squamocolumnar junction and the diaphragmatic impression was >2 cm as measured using the hash marks on the endoscope (spaced 5 cm apart) relative to the incisors (usually obscured by an opaque bite block). All endoscopies were done by a single observer. Data regarding known common risk factors of BE were recorded: duration of symptoms, obesity, age older than 50 years, male sex, tobacco use, and a family history of BE or esophageal adenocarcinoma. Details of histopathology were obtained from hospital records. The study was approved by the institutional ethics board. Descriptive statistical tests were used. A total of 188 cases (109, 58% males) formed the study cohort. The median age was 43 years (range, 18–82 years). ERD was noted in 9.6% of cases (18): Grade B (4, 2.12%), Grade C (6, 3.2%), and Grade D (4, 2.12%). BE was detected in 4 (2.12%) cases and hiatus hernia >3 cm was noted in 23 (12.2%) cases. The frequency of risk factors for BE noted in the study cohort is shown in Table 1.Table 1: Prevalence of risk factors for Barrett's esophagus in study cohortThe study highlights that the prevalence of histologically proved BE is still low in Indian setting. Our findings are similar to those reported earlier from India.[1-3,8] The reasons for low prevalence of BE in the study include single-center bias, not using enhanced mucosal imaging techniques, patients had received treatment earlier with drugs, and possibly genetic and environmental factors. The study is limited by single-center bias, retrospective design, and recruiting only patients with refractory reflux symptoms reporting to a single center. Thus, these findings are not suggestive of the true prevalence of BE. Moreover, enhanced mucosal imaging techniques like narrow band imaging were not used. This could have led to underestimation of BE. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.