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Heterotopic Gastric Mucosa in the Esophagus (Inlet Patch): An Underrecognized Entity in Patients with Various Symptoms

38

Rehman, Abdul MD; Ahluwalia, Jatinder MD

American Journal of Gastroenterology: October 2010 - Volume 105 - Issue - p S14
Abstracts: ESOPHAGUS
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Gastroenterology and Hepatology/Medicine, Southern Illinois University School of Medicine, Springfield, IL.

Purpose: Heterotopic gastric mucosa in the esophagus, also known as an inlet patch (IP) is an under-recognized condition that is often missed as a potential diagnosis in severe and refractory heartburn, dysphagia, odynophagia and globus pharyngeus. We present a case series of eight patients presenting with different upper gastrointestinal (UGI)/ esophageal symptoms who were diagnosed with IP by esophagogastroduodenoscopy (EGD).

Methods: A series of 8 patients presenting with different UGI symptoms who were diagnosed with IP between March 2008 and April 2010 by a single endoscopist.

Results: A total of 8 patients (7 female and 1 male) with a median age of 56 years (range 39-70) were diagnosed with IP. Presenting symptoms ranged from heartburn (8/8), dysphagia (5/8), nausea +/- vomiting (4/8), globus pharyngeus (3/8), and a remote history of food bolus impaction requiring endoscopic removal. Symptoms were present for 6 months in 2/8 and for many years in 6/8. The number and the size of IP varied; 4/8 had 1, 2/8 had 2 and 2/8 had 3 IPs. The patient with the most severe symptoms had the largest IP that measured 3 cm. Hiatal hernia was noted in 7/8 patients and 7/8 had biopsyproven distal reflux esophagitis. IP contained cardiac type gastric mucosa in 3/8, oxyntic type in 1/8 and unspecified gastric type mucosa in 4/8. One patient had H. Pylori gastritis without the involvement of the IP. Besides the finding of IP, there were no other endoscopic findings to explain symptoms in patients presenting with globus pharyngeus and dysphagia. None of the patients with dysphagia had difficulty with liquids. Marked relief of symptoms occurred in 7 patients who were started on a higher dose of a proton pump inhibitor (PPI) and the 8th patient reported having dysphagia upon missing PPI dose.

Conclusion: Despite a reported prevalence of up to 10% in some studies (range 0.1%-10%), IP remains an under-recognized entity. Although it is well described in the literature, it is missed frequently during endoscopy. Our series of 8 patients diagnosed with IP presented with different symptoms, including globus pharyngeus and dysphagia. Although a clear relationship between IP and these symptoms is yet to be established, absence of any other findings in our patients with globus pharyngeus and dysphagia suggests that IP may be the likely underlying etiology and should be considered in the differential diagnosis of patients presenting with these symptoms. These findings suggest that a blinded study of a larger number of patients with globus pharyngeus +/- dysphagia randomized to undergo ablation may be helpful to establish a direct relationship between these symptoms and IP.

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