Updated: 7/30/2019

Barrett Esophagus

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Snapshot
  • A 50-year-old woman complains of increased regurgitation, especially when lying down. Her father had esophageal cancer at a young age, and she is worried about also having it. She is slightly overweight and has had GERD for the past 3 years. While her PCP makes a note in her file, she reassures the patient that she does meet the requirements for routine screening for esophageal cancer, but the physician will keep an eye out on her GERD. In the meantime, the physician prescribes a proton-pump inhibitor for daily use.
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 intestinal metaplasia
  • Risk factors
    • GERD > 5-10 years
    • 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
  • Regular endoscopic surveillance to monitor risk of dysplasia and carcinoma
Prognosis, Prevention, and Complications
  • Prognosis
    • ↑ lifetime risk of esophageal cancer
      • 5% in men
      • 3% in women
    • ↑ annual risk of esophageal cancer in Barrett esophagus
      • 0.5% - 2.8% per year
  • Complications
    • progression to adenocarcinoma
    • ulceration leading to stricture formation

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Questions (4)
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(M1.GI.15.81) A 45-year-old Caucasian male presents to a gastroenterologist complaining of heartburn and difficulty swallowing. He recalls that he has been told by his primary care physician that he suffers from gastroesophageal reflux disease (GERD). The gastroenterologist decides to perform an upper endoscopy with biopsy. Which of the following findings would be consistent with Barrett's esophagus?

QID: 101138
1

Presence of Paneth cells in the lower esophagus

12%

(12/99)

2

Metaplasia in the upper esophagus

9%

(9/99)

3

A small region of red, velvet-like mucosa in the lower esophagus

76%

(75/99)

4

Esophageal varices

1%

(1/99)

5

Neutrophilic infiltration

2%

(2/99)

M 2 E

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(M1.GI.14.70) An esophageal biopsy sample from a 47-year-old male with chronic heartburn reveals intestinal metaplasia. Which of the following abnormal cell types is likely present in this patient’s esophagus:

QID: 101127
1

Pseudostratified ciliated columnar epithelium

12%

(47/385)

2

Keratinized stratified squamous epithelium

18%

(71/385)

3

Simple cuboidal epithelium

16%

(61/385)

4

Goblet cells

48%

(186/385)

5

Polymorphonuclear leukocytes

1%

(5/385)

M 2 E

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Evidence (4)
EXPERT COMMENTS (2)
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