Cervical inlet patch: case series and literature review.Abstract: Heterotopic heterotopic
pertaining to heterotopia. gastric mucosa patch (HGMP HGMP Human Genome Mapping Project
HGMP Hatchery and Genetic Management Plan ) has been reported to occur in various parts of the gastrointestinal system from mouth to anus. Extra-gastrointestinal locations have also been reported. Presence of ectopic ectopic /ec·top·ic/ (ek-top´ik)
1. pertaining to ectopia.
2. located away from normal position.
3. arising from an abnormal site or tissue.
adj. gastric mucosa has been associated with complications such as ulceration, bleeding, perforations and malignant transformations. Most complications are probably related to acid production. Meckel diverticulum diverticulum
Small pouch or sac formed in the wall of a major organ, usually the esophagus, small intestine, or large intestine (the most frequent site of problems). is the most commonly reported ectopic location. Similarly, esophageal HGMP, also known as cervical inlet patch (CIP (1) (Common Isochronous Packet) The packet format used in time-based (real time) FireWire transmission. See FireWire, IEC 61883 and mLAN.
(2) (Common Industrial P ), has been increasingly reported. Nonspecific oropharyngeal oropharyngeal /oro·pha·ryn·ge·al/ (-fah-rin´je-al)
1. pertaining to the mouth and pharynx.
2. pertaining to the oropharynx. symptoms are common and thought to be due to laryngopharyngeal reflux. CIP is often missed due to its location in the esophagus, just distal to the upper esophageal sphincter The upper esophageal sphincter (UES) refers to the superior portion of the esophagus.
Unlike the lower esophageal sphincter, it is comprised of striated muscle and is under conscious control. , making endoscopic evaluation difficult. Hence the condition is most likely to be under-reported. This article presents a series of five cases of CIP and discusses the pathogenesis, clinical presentations and management of this interesting entity.
Key Words: heterotopic gastric mucosa, presentations, complications, malignant transformations, laryngopharyngeal reflux
Heterotopic gastric mucosal patches (HGMP) are congenital gastrointestinal anomalies and have been reported to occur anywhere along the gastrointestinal system from mouth to anus. (1,2) The presence of this ectopic gastric mucosa has been associated with ulceration, bleeding, and malignant transformations. (3-5) Esophageal HGMP, also known as cervical inlet patch (CIP), is usually located just distal to the upper esophageal sphincter. CIP has been increasingly associated with oropharyngeal symptoms. Due to its postcricoid location, CIP is often missed during endoscopy. Similarly, many endoscopists may not be aware of this condition. This article presents a series of five patients with CIP and reviews the literature on the pathogenesis, clinical manifestations and their managements.
A 48-year-old woman was referred with symptoms of sore throat, dyspepsia and retrosternal discomfort that were relieved by belching belching
see eructation. . She had a negative cardiac evaluation with an exercise stress test. She did not have any underlying past medical history except for an anxious personality. Upper gastrointestinal endoscopy (EGD Esophagogastroduodenoscopy (EGD)
An imaging test that involves visually examining the lining of the esophagus, stomach, and upper duodenum with a flexible fiberoptic endoscope.
Mentioned in: Bleeding Varices
esophagogastroduodenoscopy. ) showed a flat salmon-colored patch postcricoid suggestive of HGMP (Fig. 1). Biopsy confirmed the presence of fundic type gastric mucosa. She was negative for Helicobacter pylori (H pylori) on rapid urease test rapid urease test CLO test, see there (CLOTest, Delta West Ltd, Bentley, West Australia). She was started on omeprazole 20 mg twice a day and domperidone 10 mg three times a day. Her symptoms only improved slightly. She was referred to the Ear, Nose and Throat (ENT ENT ears, nose, and throat (otorhinolaryngology).
ear, nose, and throat
ear, nose and throat.
ENT Ears, nose & throat; formally, otorhinolaryngology ) department for further evaluation. Endoscopic examination did not show any significant abnormalities except for mild congestion The condition of a network when there is not enough bandwidth to support the current traffic load.
congestion - When the offered load of a data communication path exceeds the capacity. of the vocal cords and the laryngeal laryngeal /lar·yn·ge·al/ (lah-rin´je-al) pertaining to the larynx.
la·ryn·geal or la·ryn·gal
Of, relating to, affecting, or near the larynx. mucosa. She was started on a small dose of anxiolytic anxiolytic /anx·io·lyt·ic/ (ang?ze-o-lit´ik)
2. an antianxiety agent.
A drug that relieves anxiety. in addition to her acid suppression. Her symptoms improved significantly. She remained well on maintenance acid suppression therapy on follow-up with occasional throat symptoms.
A 58-year-old Chinese man was referred from the ENT department with suspected gastroesophageal reflux disease gastroesophageal reflux disease (GERD)
Disorder characterized by frequent passage of gastric contents from the stomach back into the esophagus. Symptoms of GERD may include heartburn, coughing, frequent clearing of the throat, and difficulty in swallowing. (GERD GERD gastroesophageal reflux disease.
gastroesophageal reflux disease
GERD ). He had been seeing the ENT department with a 6 month history of throat discomfort, dryness and chronic cough that had not responded to medications. Chest radiography and electrocardiogram electrocardiogram /elec·tro·car·dio·gram/ (-kahr´de-o-gram?) a graphic tracing of the variations in electrical potential caused by the excitation of the heart muscle and detected at the body surface. examinations were normal. Endoscopic examination of the oropharyngeal space only showed congestion of the laryngeal mucosa and vocal cord, consistent with laryngopharyngeal reflux (LPR See LPR/LPD.
lpr - Line printer. The Unix print command. This does not actually print files but rather copies (or links) them to a spool area from where a daemon copies them to the printer. ). EGD showed mild gastritis and two flat salmon-colored mucosal patches just distal to the upper esophageal sphincter (Fig. 2). Biopsies from these patches confirmed the presence of fundic type gastric mucosa. He was H pylori negative by rapid urease test. He was treated with a course of acid suppression (omeprazole 20 mg twice daily) and pro-kinetic (domperidone 10 mg three times a day). His symptoms improved significantly. Repeat EGD showed that these mucosal patches had reduced in size. He is currently on maintenance acid suppression.
A 61-year-old man was referred for evaluation of constipation and dyspepsia. There were no warning symptoms. Examination did not reveal any abnormalities. He had underlying diabetes mellitus. EGD showed pangastritis with mucosal atrophy. In the proximal esophagus, there was a flat patch of salmon-colored mucosa located at 18 cm from the incisors. Proper visualization of the entire patch was difficult as it was extending proximally over the upper esophageal sphincter (Fig. 3). Biopsy from the distal part of the patch showed gastric mucosa. His gastric biopsy was H pylori positive by rapid urease test. He was treated with a one-week course of triple therapy (omeprazole 20 mg twice daily, clarithromycin 500 mg twice daily, and tinidazole 500 mg twice daily). Repeat EGD posteradication showed similar findings. Repeat testing for H pylori by histology was negative. On direct inquiry, the patient admitted to having long-standing mild throat discomfort and occasional cough. However, this had not troubled him enough to seek medical attention. He was started on acid suppression therapy on an as required basis. There were no new complaints apart from the constipation which was responding to supplemental fiber.
A 34-year-old woman with a history of throat discomfort, coughing and persistent throat clearing was referred for endoscopic evaluation. She also had symptoms consistent with GERD. Multiple ENT endoscopic examinations showed mucosal congestion of the larynx and vocal cords consistent with laryngophanyngeal reflux. She had been treated with intermittent courses of omeprazole with some relief. EGD showed two large flat patches of salmon-colored mucosa just distal to the upper esophageal sphincter at 19 cm from the incisors, characteristic of CIP. The patches measured 2 to 3 cm in size. There was also endoscopic esophagitis esophagitis /esoph·a·gi·tis/ (e-sof?ah-ji´tis) inflammation of the esophagus.
chronic peptic esophagitis reflux e. at the gastroesophageal junction (Los Angeles Grade B) and mild gastritis. She was negative for H pylori with rapid urease test and histology. She was started on an eight-week course of acid suppression (omeprazole 20 mg twice daily, with marked improvement of her symptoms). She required maintenance acid suppression therapy to control her symptoms. Her acid suppression therapy was switched to esomeprazole (Nexium, AstraZeneca) 40 mg daily due to intermittent breakthrough throat symptoms. At last follow up, she was only experiencing mild infrequent symptoms.
An 83-year-old man was referred for EGD for suspected upper gastrointestinal bleeding Upper gastrointestinal (GI) bleeding refers to hemorrhage in the upper gastrointestinal tract. The anatomic cut-off for upper GI bleeding is the ligament of Treitz, which connects the fourth portion of the duodenum to the diaphragm near the splenic flexure of the colon. . He was known to have long-standing gout and had needed regular nonsteroidal analgesia. EGD showed a geographic gastric ulcer on the lesser curve. He also had a submucosal submucosal /sub·mu·co·sal/ (-mu-ko´sal)
1. pertaining to the submucosa.
2. beneath a mucous membrane. lesion with normal overlying overlying
suffocation of piglets by the sow. The piglets may be weak from illness or malnutrition, the sow may be clumsy or ill, the pen may be inadequate in size or poorly designed so that piglets cannot escape. gastric mucosa on the lesser curve, consistent with a lipoma lipoma: see neoplasm. . Upon extubation, there were two patches of salmon-colored mucosa measuring 1 to 3 cm noted in the postcricoid area (Figs. 4 and 5). The edge of the larger proximal patch was raised and the center of the patch looked atrophic. Biopsies only showed body type gastric mucosa consistent with HGMP. There was no evidence of malignant changes on either the esophageal or gastric ulcer biopsies. H pylori testing by rapid urease test and histology was negative. The patient denied ever having any esophageal or throat symptoms. A computed tomography scan Computed tomography scan (CT scan)
A specialized type of x-ray imaging that uses highly focused and relatively low energy radiation to produce detailed two-dimensional images of soft tissue structures, particularly the brain. confirmed a submucosal lesion consistent with a lipoma. He was treated with a course and later maintained acid suppression with omeprazole. He remained well on follow up.
HGMP of the esophagus, or the cervical inlet patch, was first described by Schmidt (6) in 1805 as an aberrant gastric fundus-type epithelium located in the proximal esophagus. This ectopic mucosal patch is usually separated by 15 to 20 cm of normal squamous-lined esophagus from the gastroesophageal junction. At endoscopy, the ectopic gastric mucosa appears as a mainly flat or slightly raised, well circumscribed circumscribed /cir·cum·scribed/ (serk´um-skribd) bounded or limited; confined to a limited space.
Bounded by a line; limited or confined. red-orange salmon-colored patch. This is mainly a solitary patch but can be multiple, measuring from a few millimeters to several centimeters. (7,8) Three of our patients had two patches. In cases with multiple patches, they tend to be found on the opposite wall.
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The reported incidence of CIP in the endoscopic literature ranged from 0.29 to 10%, but incidence of up to 70% has been reported in autopsy studies. (9-11) There may be an element of underestimation of the true incidence, as the condition is commonly missed during endoscopy due to their proximal location and difficulty in examining this area. One study showed that the prevalence was higher when endoscopists were made aware and assessed for CIP compared with when endoscopists were not aware (2.27% versus 0.29% respectively). (9) Retrospective review of endoscopy done in our center showed that there was no case of CIP diagnosed until the first case was documented in 2003. Since then, there have been four additional cases documented and confirmed by histology. Three of these cases were documented in a prospective series of 392 patients undergoing upper gastrointestinal endoscopy over a period of 15 months by a single endoscopist. This gives a prevalence of 0.7% in our local setting. This is in agreement with previous reports that suggest underreporting is contributed to by unawareness of this entity by the endoscopists. (9)
The origin of HGMP is thought to be congenital in nature and CIP is thought to represent esophageal columnar embryologic remnants that had failed to transform to squamous lining during the fetal development period. Microscopically, gastric mucosa containing either cardiac, antral and potentially acid-secreting fundic mucosa can be found. (7) HGMP has been reported to occur in almost any part of the gastrointestinal tract, including the tongue, esophagus, duodenum duodenum: see intestine; pancreas.
First and shortest (9–11 in., or 23–28 cm) segment of the small intestine. It curves down and then up from the pylorus of the stomach, where chyme enters it. , gallbladder, jejunum jejunum: see intestine. , Meckel diverticulum, rectum and anus. (12-16) Extragastrointestinal locations such as the scrotum scrotum: see testis. have also been reported. (17) The most commonly reported site of HGMP is in the Meckel diverticulum. There are also reports that CIP is associated with increased risk for Barrett esophagus, suggesting a possible link. It is speculated that acid reflux causing esophagitis leading to Barrett esophagus can cause formation of CIP. (18) However, many studies have not found evidence of endoscopic Barrett in patients found to have CIP. Similarly, in our series, there was no Barrett esophagus in any of our patients. Only one of our patients had endoscopic evidence of esophagitis.
Most cases of CIP are discovered incidentally during endoscopic evaluations for other symptoms. In our series, clinical symptoms ranged from asymptomatic to protracted pro·tract
tr.v. pro·tract·ed, pro·tract·ing, pro·tracts
1. To draw out or lengthen in time; prolong: disputants who needlessly protracted the negotiations.
2. oropharyngeal symptoms. The characteristics and findings of our patients are shown in the Table. Symptoms were protracted in three patients and only responded to prolonged acid suppression. CIP is increasingly being recognized as a cause of nonspecific throat symptoms that is believed to be due to LPR. Acid production by the mucosal patch has been described and this can lead to localized ulceration leading to complications. (3,7,19) Nonspecific throat and esophageal symptoms such as cricopharyngeal spasm, upper esophageal spasm and odynophagia are usually reported.
Management of CIP depends on the symptoms and is probably related to acid secretion. (7) It is important to look for CIP in patients with protracted throat symptoms who have not responded to therapy, as prolonged potent acid suppression is effective in most cases. Trial of acid suppression with proton pump inhibitor proton pump inhibitor
A class of drugs that inhibit gastric acid secretion by interfering with the movement of hydrogen ions across cell membranes and are used mainly to treat peptic ulcers, gastroesophageal reflux disease, and esophagitis. should be given, however, the duration is not defined. In the presence of response, the patient can be put on maintenance therapy or on an as required basis. To date, there is no report as to whether treatment has any impact on the size of the CIP. The mechanism is unknown but may be due to the acid suppression leading to reduction in inflammation with subsequent regeneration of the squamous esophageal lining. For patients without response to prolonged acid suppression, they should undergo further evaluation to rule out other pathologies, especially if there are warning signs and symptoms. Often these patients have a long history of troublesome throat symptoms that may impact on their quality of life.
H pylori has been detected within the patch in up to 73% of patients who were also positive for H pylori in the stomach. The presence of H pylori in CIP has been shown to correlate with a high bacterial load in the stomach. (20) However, this is the only study that specifically assessed the presence of H pylori in the CIP. Eradication therapies should be given as the infection can lead to inflammation and ulceration. Rare complications include bleeding, stricture, perforation, fistula fistula (fĭs`chlə), abnormal, usually ulcerous channellike formation between two internal organs or between an internal organ and the skin. and esophageal malignant transformation. (4,5,21-23) In cases where there is evidence of dysplasia, management includes endoscopic mucosal resection, argon plasma coagulation Argon plasma coagulation or APC is a medical endoscopic procedure used primarily to control bleeding from certain lesions in the gastrointestinal tract, and also sometimes to debulk tumours in the case of patients for whom surgery is not recommended. and surgical resection. (24,25)
Cervical inlet patch is not uncommon, but is under-recognized due to its location in the proximal esophagus, in addition to physicians being unaware of the condition. CIP should be looked for particularly in patients with chronic cough and nonspecific oropharyngeal symptoms. Endoscopists should be aware of this condition and carefully assess the proximal esophagus just distal to the upper esophageal sphincter during endoscopy in patients with throat symptoms. This is particularly true as CIP can be associated with significant complications and rarely can lead to malignant transformation.
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ORL Orlando Executive Airport (Airport Code)
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Vui Heng Chong, MRCP MRCP Member of Royal College of Physicians.
Member of the Royal College of Physicians , FAMS FAMS Federal Air Marshals Service
FAMS Ford Academy of Manufacturing Sciences (FMC)
FAMS Fixed Assets Management System
FAMS Fuels Automated Management System
FAMS Florida Association of Mathematics Supervisors , and Anand Jalihal, MBBS MBBS, MBChB n abbr (BRIT) (= Bachelor of Medicine and Surgery) → título universitario
MBBS, MBChB n abbr (Brit) (= Bachelor of Medicine and Surgery) → , DM
From the Gastroenterology Unit, Department of Medicine, Raja Isteri Pengiran Anak Saleha Pengiran Anak Saleha (born October 7, 1946) is the Queen of Brunei and the first wife of Sultan Hassanal Bolkiah, the current Sultan of Brunei. She is the daughter of Pengiran Anak Mohamed Alam and Pengiran Anak Besar. (RIPAS) Hospital, Brunei Darussalam
Reprint requests to Vui Heng Chong; Gastroenterology Unit, Department of Medicine, Raja Isteri Pengiran Anak Saleha (RIPAS) Hospital, Bandar Seri Begawan Bandar Seri Begawan (bän`där sĕr`ē bĕgä`wän), city (1991 est. pop. 46,229), capital and chief port of the sultanate of Brunei, of which it is also the business and commercial center. BA 1710, Brunei Darussalam. Email: email@example.com
Accepted April 19, 2006.
RELATED ARTICLE: Key Points
* Cervical inlet patch or heterotopic gastric mucosa of the esophagus is not uncommon, but is an under-recognized condition.
* Symptoms are mainly related to acid production.
* Management consists of acid suppression therapy.
* It is associated with significant complications such as bleeding, ulcerations Ulcerations
Breaks in skin or mucous membranes that are often accompanied by loss of tissue on the surface.
Mentioned in: Hypersplenism , perforations and malignant transformations.
Table. Characteristics of patients, endoscopic findings and responses to treatment No. of Patient Age/gender patches Histology Symptoms Response 1 48/female 1 Fundic type Sore throat Partial response 2 58/male 2 Fundic type Sore throat Good Chronic cough response 3 61/male 1 Body type Minimal symptoms NA 4 34/femae 2 Not biopsy Sore throat Good Throat clearing response Cough 5 84/male 2 Body type Asymptomatic NA NA, not applicable.