Springer Nature is making SARS-CoV-2 and COVID-19 research free. View research | View latest news | Sign up for updates

Multilayered epithelium at the gastroesophageal junction is a marker of gastroesophageal reflux disease: data from a prospective Central European multicenter study (histoGERD trial)


Multilayered epithelium is defined as hybrid epithelium with characteristics of both squamous and columnar epithelia. Our aim was to evaluate the clinicopathological significance of the lesion by relating its presence to various histological and clinical and/or endoscopic features indicating gastroesophageal reflux disease (GERD). A total of 1,071 individuals participated in a prospective cross-sectional study (576 females and 495 males; median age 53 years). Biopsy material was systematically sampled from the gastroesophageal junction. The histological diagnosis of esophagitis was made according to the Esohisto consensus guidelines. The endoscopic diagnosis of esophagitis was made according to the modified Los Angeles classification and the diagnosis of Barrett’s esophagus according to Prague’s C & M criteria, respectively. Multilayered epithelium was identified in 103 (9.6 %) individuals, frequently within or adjacent to the ducts of esophageal glands. Its presence was associated with increasing age (p < 0.001), high BMI (p = 0.026), hiatal hernia (p < 0.001), and the endoscopic diagnoses of esophagitis (p = 0.002) and Barrett’s esophagus (p < 0.001). Upon histology, multilayered epithelium was associated with features of the squamous epithelium indicating GERD, particularly intercellular space dilation (p = 0.005), and presence of cardiac mucosa (<0.001). For intestinal metaplasia, a trend was noted (p = 0.094). In conclusion, multilayered epithelium was observed in about every tenth individual undergoing upper gastrointestinal endoscopy. The association with histological and clinical features indicating GERD advocates the lesion as a promising new marker for reflux esophagitis. The association with cardiac mucosa and Barrett’s esophagus suggests multilayered epithelium to be an intermediate step in the development of columnar metaplasia and, ultimately, Barrett’s esophagus.

This is a preview of subscription content, log in to check access.

Fig. 1
Fig. 2
Fig. 3
Fig. 4


  1. 1.

    Huang Q (2011) Definition of the esophagogastric junction: a critical mini review. Arch Pathol Lab Med 135:384–389. doi:10.1043/2010-0162-RA.1

  2. 2.

    Odze RD (2005) Unraveling the mystery of the gastroesophageal junction: a pathologist's perspective. Am J Gastroenterol 100:1853–1867

  3. 3.

    Lagergren J, Bergström R, Lindgren A, Nyrén O (1999) Symptomatic gastroesophageal reflux as a risk factor for esophageal adenocarcinoma. N Engl J Med 340:825–831

  4. 4.

    American Gastroenterological Association, Spechler SJ, Sharma P, Souza RF, Inadomi JM, Shaheen NJ (2011) American Gastroenterological Association medical position statement on the management of Barrett's esophagus. Gastroenterology 140:1084–1091. doi:10.1053/j.gastro.2011.01.030

  5. 5.

    Shields HM, Zwas F, Antonioli DA, Doos WG, Kim S, Spechler SJ (1993) Detection by scanning electron microscopy of a distinctive esophageal surface cell at the junction of squamous and Barrett's epithelium. Dig Dis Sci 38:97–108

  6. 6.

    Boch JA, Shields HM, Antonioli DA, Zwas F, Sawhney RA, Trier JS (1997) Distribution of cytokeratin markers in Barrett's specialized columnar epithelium. Gastroenterology 112:760–765

  7. 7.

    Wieczorek TJ, Wang HH, Antonioli DA, Glickman JN, Odze RD (2003) Pathologic features of reflux and Helicobacter pylori-associated carditis: a comparative study. Am J Surg Pathol 27:960–968

  8. 8.

    Glickman JN, Spechler SJ, Souza RF, Lunsford T, Lee E, Odze RD (2009) Multilayered epithelium in mucosal biopsy specimens from the gastroesophageal junction region is a histologic marker of gastroesophageal reflux disease. Am J Surg Pathol 33:818–825. doi:10.1097/PAS.0b013e3181984697

  9. 9.

    Glickman JN, Chen YY, Wang HH, Antonioli DA, Odze RD (2001) Phenotypic characteristics of a distinctive multilayered epithelium suggests that it is a precursor in the development of Barrett's esophagus. Am J Surg Pathol 25:569–578

  10. 10.

    Shields HM, Rosenberg SJ, Zwas FR, Ransil BJ, Lembo AJ, Odze R (2001) Prospective evaluation of multilayered epithelium in Barrett's esophagus. Am J Gastroenterol 96:3268–3273

  11. 11.

    Upton MP, Nishioka NS, Ransil BJ, Rosenberg SJ, Puricelli WP, Zwas FR, Shields HM (2006) Multilayered epithelium may be found in patients with Barrett's epithelium and dysplasia or adenocarcinoma. Dig Dis Sci 51:1783–1790

  12. 12.

    Srivastava A, Odze RD, Lauwers GY, Redston M, Antonioli DA, Glickman JN (2007) Morphologic features are useful in distinguishing Barrett esophagus from carditis with intestinal metaplasia. Am J Surg Pathol 31:1733–1741

  13. 13.

    von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP, Initiative STROBE (2008) The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol 61:344–349. doi:10.1016/j.jclinepi.2007.11.008

  14. 14.

    Lundell LR, Dent J, Bennett JR, Blum AL, Armstrong D, Galmiche JP, Johnson F, Hongo M, Richter JE, Spechler SJ, Tytgat GN, Wallin L (1999) Endoscopic assessment of oesophagitis: clinical and functional correlates and further validation of the Los Angeles classification. Gut 45:172–180

  15. 15.

    Hongo M (2006) Minimal changes in reflux esophagitis: red ones and white ones. J Gastroenterol 41:95–99

  16. 16.

    Sharma P, Dent J, Armstrong D, Bergman JJ, Gossner L, Hoshihara Y, Jankowski JA, Junghard O, Lundell L, Tytgat GN, Vieth M (2006) The development and validation of an endoscopic grading system for Barrett's esophagus: the Prague C & M criteria. Gastroenterology 13:1392–1399

  17. 17.

    Dixon MF, Genta RM, Yardley JH, Correa P (1996) Classification and grading of gastritis. The updated Sydney System. International Workshop on the Histopathology of Gastritis, Houston 1994. Am J Surg Pathol 20:1161–1181

  18. 18.

    Fiocca R, Mastracci L, Riddell R, Takubo K, Vieth M, Yerian L, Sharma P, Fernström P, Ruth M (2010) Development of consensus guidelines for the histologic recognition of microscopic esophagitis in patients with gastroesophageal reflux disease: the Esohisto project. Hum Pathol 41:223–231. doi:10.1016/j.humpath.2009.07.016

  19. 19.

    Dixon MF, O'Connor HJ, Axon AT, King RF, Johnston D (1986) Reflux gastritis: distinct histopathological entity? J Clin Pathol 39:524–530

  20. 20.

    Katz PO, Gerson LB, Vela MF (2013) Guidelines for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroenterol 108:308–328. doi:10.1038/ajg.2012.444

  21. 21.

    Kahrilas PJ, Shaheen NJ, Vaezi MF, Hiltz SW, Black E, Modlin IM, Johnson SP, Allen J, Brill JV; American Gastroenterological Association (2008) American Gastroenterological Association medical position statement on the management of gastroesophageal reflux disease. Gastroenterology 135:1383–1391. doi:10.1053/j.gastro.2008.08.045

  22. 22.

    Schindlbeck NE, Wiebecke B, Klauser AG, Voderholzer WA, Müller-Lissner SA (1996) Diagnostic value of histology in non-erosive gastro-esophageal reflux disease. Gut 39:151–154

  23. 23.

    Takubo K, Honma N, Aryal G, Sawabe M, Arai T, Tanaka Y, Mafune K, Iwakiri K (2005) Is there a set of histologic changes that are invariably reflux associated? Arch Pathol Lab Med 129:159–163

  24. 24.

    Zentilin P, Savarino V, Mastracci L, Spaggiari P, Dulbecco P, Ceppa P, Savarino E, Parodi A, Mansi C, Fiocca R (2005) Reassessment of the diagnostic value of histology in patients with GERD, using multiple biopsy sites and an appropriate control group. Am J Gastroenterol 100:2299–2306

  25. 25.

    Dent J (2007) Microscopic esophageal mucosal injury in nonerosive reflux disease. Clin Gastroenterol Hepatol 5:4–16

  26. 26.

    Yerian L, Fiocca R, Mastracci L, Riddell R, Vieth M, Sharma P, Franzen S, Fernstrom P, Ruth M (2011) Refinement and reproducibility of histologic criteria for the assessment of microscopic lesions in patients with gastroesophageal reflux disease: the Esohisto Project. Dig Dis Sci 56:2656–2665. doi:10.1007/s10620-011-1624-z

  27. 27.

    Bu X, Ma Y, Der R, Demeester T, Bernstein L, Chandrasoma PT (2006) Body mass index is associated with Barrett esophagus and cardiac mucosal metaplasia. Dig Dis Sci 51:1589–1594

  28. 28.

    Shaheen NJ, Weinberg DS, Denberg TD, Chou R, Qaseem A, Shekelle P; Clinical Guidelines Committee of the American College of Physicians (2012) Upper endoscopy for gastroesophageal reflux disease: best practice advice from the clinical guidelines committee of the American College of Physicians. Ann Intern Med 157:808–816. doi:10.7326/0003-4819-157-11-201212040-00008

  29. 29.

    Tobey NA, Carson JL, Alkiek RA, Orlando RC (1996) Dilated intercellular spaces: a morphological feature of acid reflux—damaged human esophageal epithelium. Gastroenterology 111:1200–1205

  30. 30.

    Calabrese C, Fabbri A, Bortolotti M, Cenacchi G, Areni A, Scialpi C, Miglioli M, Di Febo G (2003) Dilated intercellular spaces as a marker of oesophageal damage: comparative results in gastro-oesophageal reflux disease with and without bile reflux. Aliment Pharmacol Ther 8:525–532

  31. 31.

    Vieth M, Fiocca R, Haringsma J, Delarive J, Wiesel PH, Tam W, Tytgat GN, Dent J, Edebo A, Lundell L, Stolte M (2004) Radial distribution of dilated intercellular spaces of the esophageal squamous epithelium in patients with reflux disease exhibiting discrete endoscopic lesions. Dig Dis 22:208–212

  32. 32.

    Caviglia R, Ribolsi M, Maggiano N, Gabbrielli AM, Emerenziani S, Guarino MP, Carotti S, Habib FI, Rabitti C, Cicala M (2005) Dilated intercellular spaces of esophageal epithelium in nonerosive reflux disease patients with physiological esophageal acid exposure. Am J Gastroenterol 100:543–548

  33. 33.

    Chandrasoma P, Wijetunge S, Ma Y, Demeester S, Hagen J, Demeester T (2011) The dilated distal esophagus: a new entity that is the pathologic basis of early gastroesophageal reflux disease. Am J Surg Pathol 35:1873–1881. doi:10.1097/PAS.0b013e31822b78e8

  34. 34.

    Takubo K, Vieth M, Honma N, Izumiyama N, Sawabe M, Arai T, Iwakiri K, Kammori M, Mafune K (2005) Ciliated surface in the esophagogastric junction zone: a precursor of Barrett's mucosa or ciliated pseudostratified metaplasia? Am J Surg Pathol 29:211–217

  35. 35.

    Chiu PW, Ayazi S, Hagen JA, Lipham JC, Zehetner J, Abate E, Oezcelik A, Hsieh CC, DeMeester SR, Banki F, Chandrasoma P, DeMeester TR (2009) Esophageal pH exposure and epithelial cell differentiation. Dis Esophagus 22:596–599. doi:10.1111/j.1442-2050.2009.00966.x

  36. 36.

    Hahn HP, Blount PL, Ayub K, Das KM, Souza R, Spechler S, Odze RD (2009) Intestinal differentiation in metaplastic, non-goblet columnar epithelium in the esophagus. Am J Surg Pathol 33:1006–1015. doi:10.1097/PAS.0b013e31819f57e9

Download references


The authors thank Mr. Ralph König for photographic expertise and excellent technical support.

Conflict of interest

The authors declare no conflict of interest.

Author information

Correspondence to Cord Langner.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Langner, C., Wolf, E., Plieschnegger, W. et al. Multilayered epithelium at the gastroesophageal junction is a marker of gastroesophageal reflux disease: data from a prospective Central European multicenter study (histoGERD trial). Virchows Arch 464, 409–417 (2014).

Download citation


  • Multilayered epithelium
  • Prevalence
  • Metaplasia
  • Gastroesophageal junction
  • Reflux esophagitis
  • Barrett’s esophagus