Original Article
Colorectal neoplasia in veterans is associated with Barrett's esophagus but not with proton-pump inhibitor or aspirin/NSAID use

https://doi.org/10.1016/j.gie.2005.08.043Get rights and content

Background

It has been suggested that Barrett's esophagus (BE) is associated with an increased risk of developing colorectal neoplasia, but this has not been reported consistently.

Aim

To study whether BE is associated with an increased risk of colorectal neoplasia, and if it is, whether it is dependent on use of proton-pump inhibitors (PPIs) or aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs).

Design

Case-control study.

Setting

Endoscopic database of the Palo Alto Veterans Affairs Health Care System.

Population

268 veterans with BE were matched with 268 controls without BE.

Intervention

Controls had undergone upper GI endoscopy within 14 days of the corresponding case. Colonoscopy was performed within 6 months in cases and controls.

Main Outcome Measure

Development of colorectal neoplasia.

Results

Colorectal neoplasia was present in 162 of 268 (60%) BE patients and in 105 of 268 (40%) controls (p < 0.001). The presence of BE (odds ratio [OR] 2.02: 95% CI [1.35, 3.04]), but also increasing age (OR 1.24 per decade: 95% CI [1.04, 1.48]) and alcohol use (OR 1.70: 95% CI [1.16, 2.50]) were associated with an increased risk of colorectal neoplasia in multivariable logistic regression analysis, whereas PPIs (OR 0.99: 95% CI [0.66, 1.48]) and aspirin/NSAIDs (OR 0.90: 95% CI [0.61, 1.33]) had no meaningful effect.

Limitations

This was a retrospective study in mostly male veterans.

Conclusions

Veterans with BE are at an increased risk of developing colorectal neoplasia. This association is independent from the use of PPIs or aspirin/NSAIDs.

Section snippets

Patient population

Between January 1998 and December 2002, 268 veterans diagnosed with BE (cases) at the Palo Alto Veterans Affairs Health Care System underwent upper GI endoscopy as an initial procedure (n = 42) or for surveillance purposes (n = 226). BE was defined by its characteristic endoscopic appearance combined with the histologic presence of incomplete intestinal metaplasia. The cases were matched with 268 controls. Controls were selected from the endoscopy database at the Palo Alto Veterans Affairs

Patient characteristics

All cases had histologic evidence of BE (intestinal metaplasia). The mean (SD) length of the Barrett's segment at endoscopy was 2.0 (2.7) cm (range 0.5-16.0 cm). Histologic examination of BE revealed no dysplasia in 194 (72%) patients, low-grade dysplasia in 68 (25%), high-grade dysplasia in 4 (2%), and adenocarcinoma in 2 (1%) patients.

Cases were slightly older (p = 0.16) and had a lower body mass index (p < 0.01), but were comparable to controls with regard to gender and ethnicity (Table 1).

Discussion

In this large study of 268 cases and 268 controls, we found that veterans with BE were at a significantly increased risk of colorectal neoplasia compared to a group of matched veteran controls. This is in accordance with our previous findings in a study of asymptomatic veterans who were undergoing screening sigmoidoscopy for colorectal cancer and for the presence of BE. Veterans with BE in that study had adenomatous polyps more frequently than controls (8 of 27, 30% vs. 7 of 66, 11%; p = 0.04).

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  • Dr. Siersema has received research support from Janssen-Cilag and Astra-Zeneca for the conduct of other trials during the period that this study was conducted. He is the recipient of support from The Netherlands Organization for Scientific Research for a study on Barrett's esophagus. This study was conducted while Dr. Siersema was visiting Stanford University School of Medicine. His visit was partially funded by the Vereniging Trustfonds Erasmus Universiteit Rotterdam and the Dutch Digestive Diseases Foundation. Dr. Triadafilopoulos has received research support from TAP Pharmaceuticals, Pfizer, and Astra-Zeneca for the conduct of other trials during the period that this study was conducted. He is the recipient of NIH support for the study of Barrett's esophagus. He serves as a consultant and a member of the speakers' bureau to TAP, Astra-Zeneca, Pfizer, and Santarus and has received honoraria for such activities. He has also been supported by the Department of Veterans Affairs' Cooperative study program for research on colonic polyps, but not for this study. This study was conducted while Dr. Triadafilopoulos was a full-time employee of the U.S. Government. The other authors have no conflicts of interest in relation to the publication of this manuscript.

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