What is the treatment for an inlet patch in the esophagus?

Treatment of Inlet Patch in the Esophagus

Most inlet patches require no treatment and should only be photo-documented during endoscopy, with intervention reserved exclusively for symptomatic patients who fail medical management. 1

Initial Management Approach

Asymptomatic Inlet Patches

• Photo-documentation alone is sufficient for incidentally discovered inlet patches without associated symptoms 1
• The British Society of Gastroenterology provides only weak evidence (grade: weak, strength: weak) for routine intervention in asymptomatic cases 1
• No treatment is required for asymptomatic lesions discovered during routine upper endoscopy 2

When to Consider Biopsy

• Biopsy is mandatory when the patient presents with symptoms potentially attributable to the inlet patch: dysphagia, odynophagia, chronic cough, hoarseness, globus sensation, or chest pain 3, 4, 5
• Biopsy is essential when the lesion appears atypical, raised, irregular, or has features suggesting dysplasia or malignancy 3
• Biopsy should be performed to exclude complications including inflammation, ulceration, intestinal metaplasia, or adenocarcinoma 3, 6, 7
• In hereditary diffuse gastric cancer surveillance protocols, inlet patches should be registered, inspected, and biopsied 1

Medical Management for Symptomatic Patients

First-Line Acid Suppression Therapy

• High-dose proton pump inhibitors (PPIs) are the primary treatment for symptomatic inlet patches with acid-related complications 1, 5
• Combination therapy with high-dose histamine type 2 receptor antagonists plus PPIs may be used for refractory symptoms 5
• Medical management targets acid secretion from heterotopic gastric mucosa, which causes local inflammation, ulceration, and referred symptoms 4, 5, 2

Duration and Monitoring

• Continue acid suppression therapy as long as symptoms persist 5, 2
• Serial dilatation is indicated for strictures or webs that develop secondary to chronic inflammation, with mandatory biopsy to exclude malignancy before dilatation 3, 2

Endoscopic Ablation for Refractory Cases

Indications for Ablation

• Ablation should be considered when symptoms remain refractory to optimal medical management and surgical interventions 1, 4
• Small studies suggest ablation may result in symptomatic improvement in patients with reflux, globus, and dysphagia attributed to the inlet patch 1
• Endoscopic mucosal resection has been reported to ameliorate throat pain, chest pain, cough, and hoarseness in medically refractory cases 4

Important Caveats

• The clinical significance of inlet patches remains unclear, and the evidence for ablation is weak 1
• The British Society of Gastroenterology consensus was only 90% for even documenting these lesions, reflecting uncertainty about their clinical relevance 1
• Ablation should only be pursued after multidisciplinary discussion or referral to a specialist center when there is doubt about the lesion's nature 1

Critical Pitfalls to Avoid

Diagnostic Errors

• Do not overlook inlet patches during endoscopy—they appear as salmon-colored, velvety lesions easily distinguished from normal grey-white squamous epithelium, but are frequently missed on initial examinations 4, 5, 2
• Do not assume all upper esophageal symptoms are due to typical gastroesophageal reflux disease; inlet patches can cause identical symptoms including chronic cough and vocal cord dysfunction 5
• Do not fail to biopsy atypical or symptomatic lesions, as adenocarcinoma can arise from inlet patches, though this is rare 3, 4, 7

Treatment Errors

• Do not perform ablation or aggressive intervention for asymptomatic, incidentally discovered inlet patches 1, 2
• Do not dilate strictures without first obtaining biopsies to exclude malignancy 3, 2
• Do not attribute all symptoms to the inlet patch without excluding other causes of dysphagia, cough, or reflux symptoms 4, 5

Special Considerations

Associated Conditions

• Inlet patches occur in approximately 3% of patients undergoing upper endoscopy 1
• Oxyntic (acid-producing) mucosa is the most common histologic type (55%), followed by cardiac mucosa (25%) 6
• Inflammation is common (60% of cases), but intestinal metaplasia is rare 6
• Barrett's esophagus coexists in 20% of patients with inlet patches, and distal esophagitis in 25% 6
• Helicobacter pylori infection of the inlet patch correlates with antral infection and should be treated when present 6

Malignant Potential

• Adenocarcinoma arising from inlet patches is extremely rare but has been documented 4, 7
• Laryngeal carcinoma has been reported in association with inlet patches, though causality is uncertain 4
• Any atypical features warrant biopsy and consideration of endoscopic resection rather than ablation alone 3, 7