A Colour Handbook of Gastroenterology by Ralph Boulton, Sanjeev Gupta, Claire Cousins, Humphrey

By Ralph Boulton, Sanjeev Gupta, Claire Cousins, Humphrey Hodgson

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This is called the ora serrata or ‘Z’ line. In columnar-lined oesophagus, this migrates proximally as a cylinder, with islands of pink squamous mucosa or long irregular tongues of columnar mucosa rising into the oesophagus from the cardia (51). Endoscopic mucosal biopsies must be taken at multiple sites, to confirm the gastric columnar epithelium and detect dysplasia. Helicobacter pylori infection of the gastric metaplasia may also be found. Differential diagnosis Columnar-lined oesophagus lacks the rugae of stomach mucosa, which distinguishes it from sliding hiatus herniae.

Although sensitivity is less than biopsy or culture, urease tests have the advantage of convenience, simplicity, and speed (a rapid version of the test can be read in 1 min). False negative results can occur in patients with gastrointestinal bleeding, proton pump inhibitor therapy, or recent antibiotic treatment (66). Noninvasive tests Breath tests The liberation of carbon dioxide in breath following urea ingestion can be used as a marker of H. pylori infection. Fasting subjects ingest isotopically labelled urea.

Clinical history Patients present variably with cough, dysphagia, regurgitation, and weight loss. There is a risk of aspiration. Physical examination Large pouches can sometimes be palpated in the neck after food has been eaten. Laboratory and special examinations Barium swallow is the most appropriate initial investigation (47). The pouch appears as a ‘teapot spout’. Cine-radiology is helpful in early cases. Endoscopy should be performed cautiously, as the cricopharyngeal area is often a ‘blind’ region during intubation and this can be dangerous.

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