Methylene blue staining for intestinal metaplasia of the gastric cardia with follow-up for dysplasia

Background: Previous studies by our group have identified a 23% prevalence of intestinal metaplasia involving the gastric cardia in patients undergoing elective esophagogastroduodenoscopy (EGD). The current study evaluates the potential clinical utility of vital staining with methylene blue for detecting intestinal metaplasia of the cardia. In addition, the prevalence of Helicobacter pylori infection and incidence of dysplasia in cardia intestinal metaplasia was assessed. Methods: Twenty-four of 104 patients undergoing elective EGD were previously identified with cardia intestinal metaplasia. Twenty-one of these 24 returned for follow-up EGD with methylene blue staining and cardia biopsies. During EGD four random biopsies were taken in the cardia. After staining with methylene blue, four targeted biopsy specimens were taken from any stained areas. H. pylori infection was assessed by rapid urease testing and serologic evaluation. Results: Staining with methylene blue was positive in 16, equivocal in 4, and negative in 1. Overall, cardia intestinal metaplasia was identified in 17 of 21 patients (81%) by at least one of the 8 biopsies. The sensitivity of detecting intestinal metaplasia by targeted biopsies to stained areas was 67% as opposed to 38% for random biopsies (odds ratio 3.0: 95% Cl [0.88,10.24]). The prevalence of H. pylori infection in patients with cardia intestinal metaplasia was 76%. One patient developed low-grade dysplasia, whereas the others remained negative. Conclusions: Intestinal metaplasia of the gastric cardia is associated with a high prevalence of H. pylori infection and is a reproducible finding in the majority of patients. Methylene blue staining and an increasing number of biopsies improve the sensitivity of detecting this potentially neoplastic lesion.