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Updated: Dec 10 2021

Barrett Esophagus

  • Snapshot
    • A 52-year-old man presents to the emergency room with chest pain. He denies any pain with physical exertion. He just had a large, fatty, spicy meal. His cardiac work-up is negative. He has had GERD for the past ten years now but recently developed increasing heartburn and regurgitation. His BMI is 31 kg/m2. His emergency room physician recommends that he continue using proton pump inhibitors and schedules an outpatient primary care appointment for him. In a note to his PCP, he suggests a screening endoscopy.
  • Introduction
    • Metaplastic transformation of esophageal lining
      • normal squamous epithelium
      • → columnar epithelium
      • intestinal metaplasia (with globlet cells)
    • Result of chronic gastroesophageal reflux disease (GERD)
    • Risk factors
      • GERD > 5-10 years
        • 10% incidence of Barrett esophagus in GERD patients
      • age > 50 years
      • male > female
      • obesity
    • Associated conditions
      • risk of progression to adenocarcinoma
    • Pathogenesis
      • mucosal injury causes acute and chronic inflammatory change
      • esophageal stem cells develop columnar metaplasia
  • Presentation
    • Symptoms
      • heartburn
      • regurgitation
    • Physical exam
      • typically normal
    • Diagnosis with upper endoscopy with biopsy showing both
      • histology
        • metaplastic columnar epithelium with goblet cells (normally in stomach and intestines) in esophageal mucosa
      • visualization of abnormal distal esophageal mucosa
  • Differential Diagnosis
    • Erosive esophagitis
    • Gastritis
  • Treatment
    • Lifestyle modifications
      • weight loss
      • elevate head of bed
    • Proton pump inhibitor for GERD
    • Endoscopic surveillance
      • absence of dysplasia
        • repeat endoscopy in 3-5 years
      • low-grade dysplasia
        • repeat endoscopy in 6-12 months
          • most experts prefer eradication therapy with radiofrequency ablation
    • Surgical intervention for prevention of cancer with unclear benefits
  • Complications
    • Progression to adenocarcinoma
    • Ulceration leading to stricture formation
  • Prognosis
    • ↑ lifetime risk of esophageal cancer
      • 5% in men
      • 3% in women
    • ↑ annual risk of esophageal cancer in Barrett's esophagus
      • 0.5% - 2.8% per year
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