Gastric cardia
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Gastric Cardia: Etiology, Pathology, and Clinical Implications
Introduction to Gastric Cardia Adenocarcinoma
Gastric cardia adenocarcinoma is a type of cancer located at the junction of the stomach and esophagus. Unlike non-cardia gastric cancers, the incidence of cardia cancers has been increasing, particularly in Western countries . This article explores the distinct etiologies, clinical features, and pathological characteristics of gastric cardia adenocarcinoma.
Etiological Factors: pH, Helicobacter pylori, and Bile Acids
Two Distinct Etiologies
Research indicates two primary etiologies for gastric cardia adenocarcinoma. The first is associated with gastroesophageal reflux (GER) and occurs predominantly in patients without Helicobacter pylori (H. pylori) infection. This type resembles esophageal adenocarcinoma (EAC) and is linked to high acid production and bile acid reflux . The second etiology is related to H. pylori atrophic gastritis, resembling non-cardia gastric cancer. This form is associated with low acid production and high bile acid concentration, which acts as a bactericide for H. pylori in the distal stomach .
Role of Obesity and Diet
High animal fat intake leading to severe obesity is a significant risk factor for both types of cardia cancers. Central obesity contributes to the lengthening of cardiac-type mucosa and the development of partial hiatus hernia, further exacerbating GER and bile acid reflux.
Pathological Features: Intestinal Metaplasia and Cardiac Mucosa
Intestinal Metaplasia (IM)
Intestinal metaplasia of the gastric cardia is a common finding and is significantly associated with H. pylori infection. Studies show that IM is present in about 23% of patients undergoing elective endoscopy, with a notable association with H. pylori infection (p = 0.03) . IM of the cardia is more prevalent in patients with Barrett's esophagus (BE) and those who have undergone endoscopic eradication therapy (EET).
Controversy Over Normal Cardiac Mucosa
There is ongoing debate about whether the gastric cardia is a normal anatomical structure or a result of metaplastic changes due to GERD. Some studies suggest that cardiac mucosa is not a normal structure but rather a metaplastic transformation of the esophageal mucosa damaged by reflux. However, other studies argue that cardiac mucosa is present from birth and is not necessarily a response to GERD or H. pylori infection.
Clinical Features and Diagnosis
Symptoms and Diagnostic Methods
Primary incompetence of the gastric cardia can mimic symptoms of hiatal hernia and is often diagnosed through esophagoscopy, pH studies, manometry, and specialized roentgenographic studies. When medical management fails, surgical intervention to restore cardia competence is highly effective, providing dramatic and durable relief in 91% of patients.
Association with Other Conditions
Cardia cancer is more common in males and is often associated with a history of heartburn, hiatus hernia, and duodenal ulcers. The presence of H. pylori infection and chronic active gastritis in the cardia is similar to that in the antrum, suggesting a significant role of H. pylori in the inflammation and potential carcinogenesis of the cardia.
Conclusion
Gastric cardia adenocarcinoma presents with distinct etiologies and pathological features, primarily influenced by GER and H. pylori infection. Understanding these factors is crucial for accurate diagnosis and effective treatment. Further research is needed to clarify the role of cardiac mucosa and its implications in the development of cardia cancer.
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