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Indications for screening included men or women with chronic symptoms (greater than 5 years) of gastroesophageal reflux disease (GERD) and two or more risk factors for Barretts esophagus or esophageal adenocarcinoma: Caucasian race, age 50 years, chronic GERD symptoms, current or prior history of smoking, central obesity as defined as a waist circumference greater than 88 cm, waist to hip ratio greater than 0.8, family history of Barretts esophagus or family history of esophageal adenocarcinoma ( di Pietro et al., 2015 ). Patients were enrolled prospectively and consent to participate was obtained voluntarily for each patient.

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Pyles 2 1 Division of Cardiothoracic Surgery, University of Texas Medical Branch at Galveston, Galveston, TX, United States 2 Department of Microbiology and Immunology, University of Texas Medical Branch at Galveston, Galveston, TX, United States 3 Department of Preventive Medicine and Population Health, University of Texas Medical Branch at Galveston, Galveston, TX, United States 4 Division of Gastroenterology, University of Texas Medical Branch at Galveston, Galveston, TX, United States Background: The microbiome has been increasingly associated with different disease processes, but its role in esophagus is largely unknown.

Our goal was to determine the associations of the esophageal microbiota with Barretts esophagus.

Methods: A total of 74 patients were included in this prospective study, including 34 patients with Barretts esophagus and 40 patients without Barretts esophagus.

Esophageal swabs were obtained from the uvula, and mucosal biopsies were obtained from the proximal esophagus and distal esophagus in each patient.

The microbiome of each sample was assessed using a customized Esophageal Microbiome qPCR array (EMB).

For each clinical sample, we completed a detectionnon-detection analysis for each organism in the EMB.

The limit of detection (LOD) for each target was established by analysis of plasmid dilutions.

Results: Average age was 60.2 years.

There were significantly different microbial detection patterns in patients with Barretts esophagus compared to the control population.

There were a greater number of organisms which had different likelihoods of detection in the distal esophagus, compared to the proximal esophagus or uvula.

In addition, as the length of the Barretts column increased, multiple organisms were less likely to be detected.

This decreased likelihood occurred only in the distal esophagus.

Beside Barretts esophagus, no other demographic factors were associated with differences in detection patterns.

Conclusions: Microbial community structures differ between patients with and without Barretts esophagus.

Certain organisms are less likely to be detected as the severity of Barretts esophagus worsens.

These results suggest that particular organisms may have a protective effect against the development of Barretts esophagus.

It is a known risk factor for esophageal cancer ( Siersema, 2008; Domper et al., 2015 ), and patients with Barretts esophagus are recommended to undergo periodic surveillance endoscopy examinations ( Wani et al., 2016 ).

However, only 1 in 860 patients with Barretts esophagus will ultimately develop esophageal cancer ( Hvid-Jensen et al., 2011 ).

Therefore, determining which patients with Barretts esophagus are at high risk for progression to malignancy would increase the cost effectiveness of surveillance.

The role of the esophageal microbiome in promoting or preventing disease is poorly understood.

Several prior studies have shown a relationship between the microbiome and Barretts esophagus ( Yang et al., 2009; Amir et al., 2014; Snider et al., 2016; Okereke et al., 2019a ).

However, these articles have been limited and did not examine multiple locations along the esophagus.

Our goal was to examine whether the likelihood of detection of particular organisms was affected by the presence andor severity of Barretts esophagus at different locations along the esophagus.

Target organisms were identified from the literature and from data created using next generation sequencing of the 16S rRNA gene, followed by the development of a qPCR array (the Esophageal Microbiome Array; EMB) designed to evaluate greater than 85 percent of the detected species or genera in the analyzed samples.

Materials and Methods Study Participants After institutional review board approval was obtained (IRB 17-0215), 74 patients were included in the study.

All authors had access to the study data and reviewed and approved the final manuscript.

All participants were 1) patients undergoing surveillance endoscopy for a known history of Barretts esophagus or 2) patients for whom screening endoscopy was recommended or could be considered based on guidelines from the American College of Gastroenterology.

Patients were enrolled prospectively and consent to participate was obtained voluntarily for each patient.