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How should areas of ectopic gastric mucosa found in the upper esophagus be treated?
A. Sibille, D. Lacremans, N. Mahy, P. Warzée (Charleroi)
Patches of ectopic gastric mucosa could be endoscopically recognized in the upper esophagus as oval salmon-pink colored patches. The reported prevalence of the so-called "inlet patch" varies widely in the literature. It is problably underdiagnosed in routine endoscopy because the examination of the upper esophagus is usually not thoroughly performed by the gastroenterologist in the absence of symptoms related to upper dysphagia. The highest prevalence rates were found in prospective studies that were specifically looking for those areas. A necropsy study in children identified the lesion in 21% of the cases . Endoscopy series in adults usually reported rates of 3-5%  but it is worth noticing that a 10% prevalence was found by some authors .
The pathogenesis of ectopic gastric mucosa is a matter of debate between a congenital - embryological - and an acquired origin - consecutive to a gastroesophageal reflux (GER) like Barrett's esophagus -, the most commonly accepted theory being that these areas are embryological remnants. This hypothesis is supported by the following arguments. During fetal life the esophagus is lined by a columnar epithelium which is secondarily replaced by a squamous epithelium. The incidence of ectopic gastric mucosa seems to be higher in the childhood, particularly during the first year, and apparently declines with advancing years . These patches are almost always located in the upper esophagus and other reflux associated lesions of the lower esophagus (hiatal hernia, esophagitis, Barrett's epithelium) often are not found in these patients . A malignant potential of the ectopic gastric mucosa through a metaplasia-dysplasia sequence like in Barrett's esophagus has never been proven. In addition, some authors found a difference in the hormonal secretion profile measured by immunohistochemical methods between ectopic gastric mucosa of the upper esophagus and Barrett's esophagus [4, 5].
However none of these arguments rules out definitively the acid reflux hypothesis especially in relationship with some other findings reported in the litterature. Bogomoletz  reported that the mucin histochemistry of ectopic gastric mucosa was different from that of the heterotopic gastric mucosa found into the Meckel's diverticula, a lesion of developmental origin, but had several similarities with that of Barrett's esophagus. Jacobs  reported a significantly higher rate of esophagitis in the group of patients with ectopic gastric mucosa. Although this is a rare lesion, the presence of intestinal metaplasia (IM) in ectopic gastric mucosa patches has been described by Jacobs (3 cases) , Bogomoletz (3 cases) , Truong (1 case)  and our group (3 cases) . Moreover, one case of preneoplastic lesion (adenoma with high-grade dysplasia - HGD)  and about fifteen cases of adenocarcinoma arising in ectopic gastric mucosa [10-12] have been reported. All these reports render a probable relationship between Barrett's esophagus and ectopic gastric mucosa relevant. Both hypothesis however are not mutually exclusive. GER can affect an underlying congenital abnormality .