Is a biopsy necessary to diagnose and treat an inlet patch?

Biopsy of Inlet Patch: Not Routinely Required for Diagnosis, But Essential in Specific Clinical Scenarios

Photo-documentation of an inlet patch is recommended, but routine biopsy is not necessary for asymptomatic lesions discovered incidentally during upper endoscopy. 1

When Biopsy Is NOT Required

The British Society of Gastroenterology guidelines explicitly state that inlet patches should be photo-documented but provide only a weak recommendation for biopsy, with 90% consensus agreement. 1 This reflects the clinical reality that most inlet patches are:

• Asymptomatic incidental findings discovered in approximately 3-10% of patients undergoing upper endoscopy 2, 3
• Easily recognized endoscopically by their characteristic salmon-colored, velvety appearance that contrasts sharply with the normal grey-white squamous epithelium of the esophagus 2
• Benign lesions that require no treatment when asymptomatic 2

The diagnosis is strongly suggested by the endoscopic appearance alone—well-demarcated salmon-red plaques in the cervical esophagus, typically at or just distal to the upper esophageal sphincter. 2, 4

When Biopsy IS Indicated

Biopsy becomes essential in the following specific clinical scenarios:

1. Symptomatic Patients

When patients present with symptoms potentially attributable to the inlet patch, including: 5, 4

• Dysphagia or odynophagia
• Chronic cough or hoarseness
• Laryngopharyngeal reflux symptoms refractory to standard therapy
• Chest pain or globus sensation

In these cases, biopsy confirms the presence of gastric mucosa (oxyntic, cardiac, or fundic type) and can identify complications such as inflammation, ulceration, or intestinal metaplasia. 5, 3

2. Complicated Inlet Patches

Biopsy is mandatory when complications are suspected or identified: 2, 3

• Stricture formation: Strictures should be biopsied to exclude malignancy before dilatation 1, 6
• Ulceration or severe inflammation: To assess severity and guide treatment
• Atypical appearance: Any deviation from the classic salmon-colored patch warrants tissue diagnosis

3. Exclusion of Malignancy

While rare, adenocarcinoma can arise from inlet patches. 7 Biopsy is indicated when:

• The lesion appears atypical, raised, or irregular
• There are endoscopic features suggesting dysplasia or malignancy
• Symptoms are progressive or refractory to acid suppression therapy

The case literature documents transformation to adenocarcinoma, making tissue diagnosis prudent in suspicious cases. 5, 7

4. Assessment of Associated Pathology

Recent evidence suggests a potential association between inlet patch inflammation severity, gastric inflammation, and H. pylori infection. 4 When moderate-to-severe gastritis is present elsewhere in the stomach, or when H. pylori is detected, biopsy of the inlet patch may help:

• Assess the degree of inflammation within the heterotopic mucosa
• Identify intestinal metaplasia, which was found in some symptomatic cases 5
• Guide treatment decisions regarding acid suppression and H. pylori eradication

Practical Algorithm for Clinical Decision-Making

For incidentally discovered inlet patches:

1. Photo-document the lesion 1, 6
2. If asymptomatic and typical appearance → No biopsy required
3. If symptomatic or atypical → Proceed with biopsy

For symptomatic patients with inlet patch:

1. Obtain biopsy to confirm gastric mucosa and assess for complications 2, 5
2. Evaluate for inflammation, ulceration, intestinal metaplasia, or dysplasia
3. Assess remainder of stomach for H. pylori and gastritis severity 4
4. Initiate proton pump inhibitor therapy based on findings 2, 3, 4

For complicated inlet patches (stricture, ulcer, atypical features):

1. Mandatory biopsy to exclude malignancy 1, 2, 3
2. Multiple biopsies if lesion is large or irregular 7
3. Consider endoscopic mucosal resection for refractory symptomatic cases 5

Common Pitfalls to Avoid

• Over-biopsying asymptomatic lesions: The weak recommendation for routine biopsy reflects that most inlet patches are benign and require only documentation 1
• Under-recognizing symptomatic cases: Symptoms may be subtle (chronic cough, hoarseness) and attributed to other causes when an inlet patch is actually contributory 5, 4
• Missing strictures: Always biopsy strictures before dilatation to exclude malignancy, even when an inlet patch is the presumed cause 1, 6, 3
• Ignoring the malignant potential: While rare, adenocarcinoma can develop, particularly in symptomatic or atypical lesions 7