Diagnosis of Barrett’s esophagus in University Hospital Centre Zagreb between 2012 and 2017

To evaluate epidemiology and demographic data of patients diagnosed with Barrett’s esophagus in Zagreb between January 2012 and December 2017. Endoscopy suspicion of esophageal metaplasia (ESEM) was made in 592 patients. Pathohistological confirmation of Barrett’s esophagus was established in 163 patients (0.8%). Intestinal metaplasia without dysplasia was diagnosed in 137 patients, low grade dysplasia in 20 patients, high grade dysplasia in three and early cancer in three patients. In the group of 163 patients with confirmed Barrett’s esophagus 116 (71%) were male and 47 (29%) were female with median age of 58 years. Hiatal hernia was observed during endoscopy in 92 patients (56%).


MATERIALS AND METHODS
In a 6 year period, upper GI endoscopy was performed in 19950 patients. We have analysed endoscopy and hospital database regarding pathohistological confirmation and demographic data of patients diagnosed with Barrett's esophagus .

RESULTS
Endoscopy suspicion of esophageal metaplasia (ESEM) was made in 592 patients.
Pathohistological confirmation of Barrett's esophagus was established in 163 patients (0.8%). Intestinal metaplasia without dysplasia was diagnosed in 137 patients, low grade dysplasia in 20 patients, high grade dysplasia in three and early cancer in three patients.
In the group of 163 patients with confirmed Barrett's esophagus 116 (71%) were male and 47 (29%) were female with median age of 58 years. Hiatal hernia was observed during endoscopy in 92 patients (56%).
Patients with high grade dysplasia and early cancer have been treated with bandEMR and then radio frequency ablation (RFA), and all the patients with confirmed low grade dysplasia have been treated with RFA.

CONCLUSION
Barrett's esophagus still has a low incidence in Croatia, even in a high volume tertiary referral Centre. Background 3 Barrett's esophagus (BE) is characterised by a change of normal stratified squamous epithelium lining the esophagus to a metaplastic columnar epithelium with goblet cells. BE is a premalignant condition predisposing to esophageal adenocarcinoma (EAC) 1

Methods
We conducted a single centre retrospective and descriptive study, reviewing the medical records of patients seen in Endoscopy unit of University Hospital Centre Zagreb Croatia, that underwent upper gastrointestinal endoscopy between January 2012 and December 2017.
Materials were collected from medical databases ISSA (endoscopy database) and BIS (intrahospital database). All patients underwent high resolution white light endoscopy, conducted by consultant gastroenterologist in our Endoscopy unit.. BE was characterised as short-segment (SSBE) <3cm or long-segment (LSBE) >3cm, with Prague classification 4 .
Biopsies were taken according to Seattle protocol 5 and additional in areas suspicious for dysplasia. BE was confirmed by positive identification of histopathological reports made by pathologist, and in case of dysplasia double-blind pathology review.
In addition, signs of GERD and hiatal hernia during endoscopy were also noted.
From intrahospital database data regarding to patients age, sex, smoking, body mass index, family history and any additional medical, endoscopic or surgical treatments were registered.

Discussion
According to our results, prevalence of BE in our single tertiary refferal Centre is 0.8% which is lower than reported in international case series. Italian study reported a prevalence of 1.3%, which was conducted on 1033 individuals 4 , while in Canada confirmed Barrett was present in 2.4% of 1040 cases. 6 In Sweden prevalence of BE was 1.6% from cohort of 1000 healthy individuals who were represented as general population. 7 From study conducted in Leicester General Hospital in period of 10 years (1984-94), BE prevalence was 1.4% of all endoscopies. 8 Also, our prevalence was lower than overall prevalence in eastern Asian countries, which had the pooled prevalence of 1.3%. 9 Reason for lower prevalence could be that our study was conducted in only one hospital centre in small time period of six years. These findings can be related to Mexican study which was also conducted in one hospital centre. Their results showed a prevalence of 0.96% or 9.6 cases on 1000 patients. 10 Similar low prevalence of 0.24% was recorded in Lebanon, which was also conducted in one hospital centre in time period of ten years. 11 Regarding the patients age and sex, our findings are similar to international studies. All of them have a consensus that BE is more common in male patients with mean age higher than 50 years. [6][7][8][9][10][11] 6 BMI of BE patients with or without dysplasia showed that most of the patients are overweight with average BMI of 27.14. Some studies connected BMI with length of BE. BMI was significantly higher in patients with LSBE as compared to patients with SSBE 12 .Same correlations were detected in our group of BE patients.
Our study showed that 16% of patients had dysplasia, which is similar to international case series. The grade of dysplasia was also the same, with higher number of low dysplasia and lower numbers of high dysplasia and adenocarcinoma. [6][7][8][9][10][11] It is safe to say that our standard of care of BE patients is up to date with current guidelines for BE 1 . For surveillance of BE high definition endoscopy is used. In endoscopy reports extent of BE using Prague classification, description of location of any visible abnormality and location of taken biopsies are regularly reported. Biopsies are taken from all visible mucosal abnormalities and 4-quadrant random localisations.
In conclusion, according to the present study BE still has low incidence in Croatia, even in a high volume tertiary referral Centre. Declarations AKNOWLEDGMENTS This work was supported by University Hospital Centre Zagreb and Croatian Gastrointestinal Society.

DISLCOSURES
We have no conflicts of interest to disclose.
All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1964 and later versions. Informed consent or substitute for it was obtained from all patients for being included in the study.