Review Question - QID 107751

This patient with Barrett's esophagus as a consequence of prolonged GERD runs a risk of developing esophageal cancer if left untreated, due to repetitive mucosal damage by stomach acid. The pathology in this scenario is most often adenocarcinoma of the esophagus.

Barrett's esophagus is a complication of GERD. Barrett's esophagus is hypothesized to occur due to chronic inflammation causing metaplasia from stratified squamous epithelium to columnar cells. Barrett's esophagus carries an absolute risk of incidence of esophageal cancer of around 0.61% per year for patients. Interestingly, one systematic review by Yousef et al. found that the rate of conversion to cancer occurred twice at the rate in men when compared to women. Other risk factors include age >45 years, extensive disease segment, white race, obesity, family history of gastric cancer, severe and frequent reflux symptoms, and mucosal damage such as ulceration and stricture. When esophageal carcinoma does present, adenocarcinoma is far most common.

Heidelbaugh et al. discuss the diagnosis and management of GERD and Barrett's esophagus. With regard to the diagnosis of Barrett's they recommend diagnostic testing in patients who do not respond to continuous acid suppression therapy, or who exhibit warning signs or have a risk factor for Barrett's mainly: white male of age > 45 years and long duration of symptoms. That said, regular screening for progression to adenocarcinoma is controversial, with a lack of evidence to support its efficacy in reducing mortality from adenocarcinoma (Illustration A).

Shaheen et al. discuss clinical guidelines addressing upper endoscopy for GERD. Mainly, they suggest endoscopy in patients with heartburn and alarm symptoms (dysphagia, bleeding, anemia, weight loss, and recurrent vomiting). They recommend endoscopy in patient with GERD only after symptoms persist despite extensive proton pump inhibitor therapy. They suggest that upper endoscopy may be indicated in men older than 50 with chronic GERD (greater than 5 years) with additional risk factors (nocturnal reflux, hiatal hernia, elevated BMI, tobacco use, and intra-abdominal distribution of fat).

Illustration A is a diagnosis and treatment algorithm for patients presenting with GERD in patients with no warning signs or symptoms that suggest complicated disease.

Incorrect Answers:
Answer 2: SCC is not as common as adenocarcinoma as a sequelae of Barrett's esophagus. Risk factors for SCC of the esophagus include tobacco and alcohol consumption.
Answer 3: Transitional cell carcinoma is a cancer of the urinary bladder. Cyclophosphamide is a risk factors for this disease, especially when given without mesna.
Answer 4: GISTs are mostly heritable tumors, with mutations to KIT and PDGFRA being genetic risk factors.
Answer 5: MALT lymphoma is not associated with Barrett's esophagus, though importantly it is highly associated with Helicobacter pylori infection.