What is an esophageal inlet patch?

What is an Esophageal Inlet Patch?

An esophageal inlet patch is a congenital anomaly consisting of ectopic (heterotopic) gastric mucosa located in the cervical esophagus, typically at or just distal to the upper esophageal sphincter. 1, 2, 3

Epidemiology and Pathophysiology

• Inlet patches occur in approximately 1-3% of patients undergoing upper endoscopy 1, 4
• The lesion represents remnants of fetal columnar epithelium that failed to be replaced by squamous epithelium during embryogenesis 5
• The most common location is the postcricoid portion of the esophagus at or just below the upper esophageal sphincter 6

Histologic Characteristics

• Oxyntic (fundic) mucosa is the most common histologic type (55% of cases), followed by cardiac mucosa (25%) 4
• Inflammation is common, occurring in approximately 60% of inlet patches 4
• Pancreatic acinar tissue may be present in about 10% of cases 4
• Intestinal metaplasia is rare but has been documented 4, 6

Clinical Presentation

Asymptomatic Cases

• Most inlet patches are asymptomatic and discovered incidentally during endoscopy 1, 3

Symptomatic Cases

When symptomatic, inlet patches can cause:

• Dysphagia and odynophagia from acid-related complications 1, 2
• Chronic cough and hoarseness from laryngopharyngeal reflux 7, 6
• Globus sensation (feeling of a lump in the throat) 1, 7
• Chest pain 6

Diagnostic Approach

Endoscopic Appearance

• The lesion appears salmon-colored and velvety, easily distinguished from the normal grey-white squamous epithelium of the esophagus 3
• Prominent margins create characteristic indentations visible on both endoscopy and barium swallow 3

Biopsy Indications

• Photo-documentation alone is sufficient for incidentally discovered, asymptomatic inlet patches 1, 2
• Biopsy is mandatory when patients present with symptoms potentially attributable to the inlet patch (dysphagia, odynophagia, chronic cough, hoarseness, globus sensation, or chest pain) 2
• Biopsy is essential when the lesion appears atypical, raised, irregular, or has features suggesting dysplasia or malignancy 1, 2

Associated Conditions and Complications

Common Associations

• Distal esophagitis occurs in approximately 25% of patients with inlet patches 4
• Barrett's esophagus is present in about 20% of patients with inlet patches 4
• Helicobacter pylori infection of the inlet patch correlates with antral H. pylori infection 4

Rare but Serious Complications

• Stricture and web formation from chronic acid-related injury 3, 6
• Adenocarcinoma development is a rare but documented malignant transformation 6, 5
• One case report documented laryngeal carcinoma in association with an inlet patch, though causality remains uncertain 6

Clinical Significance

• The clinical significance remains unclear, with the British Society of Gastroenterology achieving only 90% consensus for even documenting these lesions 1
• However, when symptomatic and refractory to treatment, inlet patches can cause significant morbidity affecting quality of life through chronic respiratory symptoms and dysphagia 7, 6
• The malignant potential exists but is extremely rare, warranting biopsy only in atypical or symptomatic cases 5