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) Pathogenesis mucosal injury causes acute and chronic inflammatory change esophageal stem cells develop columnar metaplasia 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 Presentation Symptoms heartburn regurgitation Physical exam typically normal Evaluation 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 every 3 months (for high-grade dysplasia) to 2 years (metaplasia) to monitor risk of carcinoma Surgical intervention for prevention of cancer with unclear benefits Prognosis, Prevention, and Complications 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 Complications progression to adenocarcinoma ulceration leading to stricture formation