Helicobacter pylori and Hetertopic Gastric Mucosa in the Upper Esophagus (the Inlet Patch) Oscar Gutierrez, M.D., Taiji Akamatsu, M.D., Hector Cardona, M.D., David Y. Graham, M.D., and Hala M.T. El-Zimaity, M.D. Gastrointestinal Mucosa Pathology Laboratory, Department of Medicine, Department of Pathology, Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas, USA; Department of Endoscopy, Shinshu University Hospital, Matsumoto, Japan; and Department of Gastroenterology, National University of Colombia, Bogota, Colombia OBJECTIVES: Helicobacter pylori (H. pylori) may colonize gastric mucosa wherever it is found in the GI tract. Heter- otopic gastric mucosa in the upper esophagus (inlet patch) is a potential site for H. pylori infection and may provide a reservoir for oral-oral transmission or a niche where antibi- otics might have difficulty reaching. The aim of this study was to analyze the intensity and distribution of H. pylori in the inlet patch. METHODS: Whenever a cervical inlet patch was observed, mucosal biopsy samples were taken to confirm the endo- scopic diagnosis and to search for H. pylori and active inflammation. In addition, mucosal biopsy samples were also taken from the gastric mucosa. Formalin-fixed biopsy specimens were cut and stained with a new dual stain developed in our laboratory. The stain is a combination of periodic acid-Schiff and a silver stain that allows simulta- neous visualization of H. pylori and gastric type epithelium. The density of H. pylori was scored using a visual analog scale of 0 to 5. The type of mucosa in the inlet patch was also recorded. RESULTS: The study included 48 patients; 37 had H. pylori gastritis and 27 of these (73%) had H. pylori identified on their heterotopic gastric mucosa. A higher density of H. pylori in the stomach was associated with a higher preva- lence in the inlets. Active inflammation correlated with active infection in the inlet patch and the presence of antral type mucosa. CONCLUSION: H. pylori colonization of heterotopic gastric mucosa in the upper esophagus is common and is closely related to the H. pylori density in the stomach. The fact that H. pylori was not found in all cases suggests that another event such as reflux may be required for H. pylori to colo- nize heterotopic mucosa. (Am J Gastroenterol 2003;98: 1266 –1270. © 2003 by Am. Coll. of Gastroenterology) INTRODUCTION Gastric type mucosa occurring in the upper one third of the esophagus within 3 cm of the upper esophageal sphincter is designated the “inlet patch.” Macroscopically, the inlet patch typically has a deep pink, velvety appearance; it presents either as a single patch or as multiple patches of gastric mucosa situated just below the upper esophageal sphincter. Microscopically, the patch can be lined with either cardiac type glands or gastric body type mucosa. As inlet patches are typically small (size range, 1 cm to 5 cm) (1), the presence of an inlet patch is often overlooked at endoscopy; the chance of it being discovered is related to size. Inlet patches are found in approximately 2– 4% of esoph- agi (2, 3) in all age groups. They are generally considered an incidental congenital finding, and most patients have no symptoms referable to the inlet patch. Nonetheless, the patch can become the site of small peptic erosions/ulcers, stenosis, fistula, intestinal metaplasia (4), high grade dys- plasia (5, 6), or adenocarcinoma (7–11). We report a pro- spective observational study designed to examine the rela- tionship of Helicobacter pylori (H. pylori) colonization of heterotopic gastric mucosa at the upper esophagus (i.e., inlet patches). MATERIALS AND METHODS Study Patients Over a 1-yr recruitment period, cervical inlet patches were specifically looked for in patients undergoing upper GI endoscopy at the University Hospital of the National Uni- versity of Colombia, Bogota, Colombia. Patients were re- ferred for endoscopy for a variety of reasons, primarily for evaluation of dyspepsia. Heterotopic gastric mucosa of the upper esophagus was identified as salmon-rose patches that were clearly distinct from the adjacent grayish-pearly esophageal mucosa (Fig. 1). Mucosal biopsy samples were taken from the inlet patch (before the endoscope entered the stomach) and from the gastric mucosa. Gastric mucosal THE AMERICAN JOURNAL OF GASTROENTEROLOGY Vol. 98, No. 6, 2003 © 2003 by Am. Coll. of Gastroenterology ISSN 0002-9270/03/$30.00 Published by Elsevier Inc. doi:10.1016/S0002-9270(03)00267-3