Barrett esophagus - Clinicals, Diagnosis, and Management

Upper GI

Clinicals - History

Fact Explanation
Diagnosed incidentally on screening Barrett esophagus is the metaplasia of the lower esophageal squamous epithelium in to columnar epithelium(gastric-fundic type, cardia-type, or intestinal-type). It is commonly seen in middle aged males. Barrett esophagus is the precursor of esophageal adenocarcinoma and the risk of adenocarcinoma is about 0.4–0.5% per year. Males and patients with long segment Barrett esophagus are at higher risk. Diagnosed incidentally on screening
Barrett esophagus is the metaplasia of the lower esophageal squamous epithelium in to columnar epithelium(gastric-fundic type, cardia-type, or intestinal-type). It is commonly seen in middle aged males. Barrett esophagus is the precursor of esophageal adenocarcinoma and the risk of adenocarcinoma is about 0.4–0.5% per year. Males and patients with long segment Barrett esophagus are at higher risk.
Asymptomatic Some patients with Barrettt esophagus are asymptomatic. Asymptomatic
Some patients with Barrettt esophagus are asymptomatic.
History of gastroesophageal reflux disease (GERD) Barrett esophagus is secondary to long term exposure to gastric acid contents in patients with gastroesophageal reflux disease (GERD). Patients have a history of acid regurgitation into the mouth and heartburn. History of gastroesophageal reflux disease (GERD)
Barrett esophagus is secondary to long term exposure to gastric acid contents in patients with gastroesophageal reflux disease (GERD). Patients have a history of acid regurgitation into the mouth and heartburn.
Dysphagia Some patients with Barrett's esophagus can have dysphagia if a stricture is present. Stricture is usually due to esophageal scarring. Dysphagia
Some patients with Barrett's esophagus can have dysphagia if a stricture is present. Stricture is usually due to esophageal scarring.

Clinicals - Examination

Fact Explanation
BMI Many patients with GERD are obese. Other system examination is usually normal in patients with Barrett esophagus. BMI
Many patients with GERD are obese. Other system examination is usually normal in patients with Barrett esophagus.
Signs of respiratory tract infection Patients with GERD can have respiratory tract infections secondary to aspiration of gastric contents in to the bronchi. Patients are febrile, and have evidence of pulmonary consolidation. Commonly over the base of the right lung. Signs of respiratory tract infection
Patients with GERD can have respiratory tract infections secondary to aspiration of gastric contents in to the bronchi. Patients are febrile, and have evidence of pulmonary consolidation. Commonly over the base of the right lung.

Investigations - Diagnosis

Fact Explanation
Upper gastrointestinal endoscopy (UGIE) UGIE can detect the dysplastic epithelium by the presence of salmon-pink colored luminal extensions (“tongues”) of mucosa. If the dysplastic segment is more than 7cm it is called a long segment Barrett and if less than 7cm it is called short segment Barrett esophagus. Upper gastrointestinal endoscopy (UGIE)
UGIE can detect the dysplastic epithelium by the presence of salmon-pink colored luminal extensions (“tongues”) of mucosa. If the dysplastic segment is more than 7cm it is called a long segment Barrett and if less than 7cm it is called short segment Barrett esophagus.
24 hour esophageal PH monitoring This test can detect the presence and the degree of gastroesophageal reflux. Patients with short segment Barrett esophagus have reflux only during the upright position. Patients with long segment Barrett esophagus have demonstrable reflux in both supine and upright positions. 24 hour esophageal PH monitoring
This test can detect the presence and the degree of gastroesophageal reflux. Patients with short segment Barrett esophagus have reflux only during the upright position. Patients with long segment Barrett esophagus have demonstrable reflux in both supine and upright positions.
Biopsy of the suspicious lesions Presence of columnar epithelium and goblet cells are indicative of metaplasia of the squamous epithelium. These cells contain large cytoplasmic vacuoles filled with mucin, which are stained blue. Biopsy of the suspicious lesions
Presence of columnar epithelium and goblet cells are indicative of metaplasia of the squamous epithelium. These cells contain large cytoplasmic vacuoles filled with mucin, which are stained blue.

Investigations - Management

Fact Explanation
Endoscopic ultrasonography (EUS) When high grade dysplasia is diagnosed EUS is helpful in evaluating the local spread and the surgical resectability of the dysplastic segment. However its use is still controversial. Endoscopic ultrasonography (EUS)
When high grade dysplasia is diagnosed EUS is helpful in evaluating the local spread and the surgical resectability of the dysplastic segment. However its use is still controversial.
Upper gastrointestinal endoscopy (UGIE) UGIE is used in screening of patients with GORD. Biopsy specimens can be obtained from any suspicious lesions for the histological confirmation of the adenocarcinoma. In patients with endoscopic evidence of dysplasia annual endoscopic surveillance is indicated. If the subsequent endoscopies shows no dysplasia for two consecutive years endoscopy is done in every 3 years. Patients with persistent low-grade dysplasia should undergo endoscopic surveillance once in every 6 months intervals for a year and if they shows no progression of the lesions annual surveillance is adequate. Upper gastrointestinal endoscopy (UGIE)
UGIE is used in screening of patients with GORD. Biopsy specimens can be obtained from any suspicious lesions for the histological confirmation of the adenocarcinoma. In patients with endoscopic evidence of dysplasia annual endoscopic surveillance is indicated. If the subsequent endoscopies shows no dysplasia for two consecutive years endoscopy is done in every 3 years. Patients with persistent low-grade dysplasia should undergo endoscopic surveillance once in every 6 months intervals for a year and if they shows no progression of the lesions annual surveillance is adequate.

Management - Supportive

Fact Explanation
Health education Patients with GERD should be advised about the risk of progression in to Barrett esophagus and adenocarcinoma. (0.12% annual risk in patients with Barrett esophagus which increases up to 0.26% in patients with high grade dysplasia.) Obese patients with GERD should reduce weight. Patients should not take heave meals, lie down or bend forwards within about 3 hours of meals. It is better to avoid fatty foods, chocolate, coffee, carbonated beverages, citrus fruit juices, smoking and alcohol. Health education
Patients with GERD should be advised about the risk of progression in to Barrett esophagus and adenocarcinoma. (0.12% annual risk in patients with Barrett esophagus which increases up to 0.26% in patients with high grade dysplasia.) Obese patients with GERD should reduce weight. Patients should not take heave meals, lie down or bend forwards within about 3 hours of meals. It is better to avoid fatty foods, chocolate, coffee, carbonated beverages, citrus fruit juices, smoking and alcohol.
Anti-reflux surgery Patients with symptomatic GERD benefit from anti-reflux surgery, but it is not proven to cause regression of the Barrett's segment. Anti-reflux surgery
Patients with symptomatic GERD benefit from anti-reflux surgery, but it is not proven to cause regression of the Barrett's segment.
Management of esophageal strictures Patients with esophageal strictures and dysphagia will benefit from esophageal dilatation. Management of esophageal strictures
Patients with esophageal strictures and dysphagia will benefit from esophageal dilatation.

Management - Specific

Fact Explanation
Proton pump inhibitors (PPIs) High dose PPIs are proven to reduce the degree of reflux. So all the patients with GERD should be on PPIs. Proton pump inhibitors (PPIs)
High dose PPIs are proven to reduce the degree of reflux. So all the patients with GERD should be on PPIs.
Non-steroidal anti-Inflammatory drugs (NSAIDs) and aspirin NSAIDs inhibit the synthesis of prostaglandin E2 which stimulates the growth of the tumor cells, angiogenesis and inhibits apoptosis. By inhibiting the synthesis of prostaglandin E2 NSAIDs reduces the tumor growth and angiogenesis. Non-steroidal anti-Inflammatory drugs (NSAIDs) and aspirin
NSAIDs inhibit the synthesis of prostaglandin E2 which stimulates the growth of the tumor cells, angiogenesis and inhibits apoptosis. By inhibiting the synthesis of prostaglandin E2 NSAIDs reduces the tumor growth and angiogenesis.
Statins Statins inhibit the proliferation of tumor cells and promote apoptosis. Statins
Statins inhibit the proliferation of tumor cells and promote apoptosis.
Endoscopic radiofrequency ablation (RFA) RFA is recommended for the treatment of patients with low grade and high grade dysplasia. This procedure carries a risk of developing upper gastrointestinal bleeding and esophageal stricture. RFA is effective in ablating Barrett esophagus. Low grade dysplastic lesions can be successfully ablated than high grade dysplastic lesions by RFA. Endoscopic radiofrequency ablation (RFA)
RFA is recommended for the treatment of patients with low grade and high grade dysplasia. This procedure carries a risk of developing upper gastrointestinal bleeding and esophageal stricture. RFA is effective in ablating Barrett esophagus. Low grade dysplastic lesions can be successfully ablated than high grade dysplastic lesions by RFA.
Photodynamic therapy (PDT) Some patients develop photosensitivity reactions. Photodynamic therapy (PDT)
Some patients develop photosensitivity reactions.
Argon plasma coagulation (APC) APC is commonly used for patients with non-dysplastic Barrett's esophagus. Chest pain is the commonest complication of the procedure. Other uncommon complications include esophageal strictures, fever, bleeding, esophageal perforation and death. Argon plasma coagulation (APC)
APC is commonly used for patients with non-dysplastic Barrett's esophagus. Chest pain is the commonest complication of the procedure. Other uncommon complications include esophageal strictures, fever, bleeding, esophageal perforation and death.
Multipolar electrocoagulation (MPEC) This is another endoscopic treatment option for the treatment of Barrett esophagus. Multipolar electrocoagulation (MPEC)
This is another endoscopic treatment option for the treatment of Barrett esophagus.
Endoscopic heater probes Heater probes are used to deliver thermal energy to the dysplastic cells and to cause lysis of tumor cells. Endoscopic heater probes
Heater probes are used to deliver thermal energy to the dysplastic cells and to cause lysis of tumor cells.
Endoscopic mucosal resection (EMR) EMR is an effective treatment option for the treatment of low-grade dysplastic lesions. All the suspicious, irregular and nodular mucosal areas are resected in this procedure. Endoscopic mucosal resection (EMR)
EMR is an effective treatment option for the treatment of low-grade dysplastic lesions. All the suspicious, irregular and nodular mucosal areas are resected in this procedure.
Cryotherapy Cryogen (liquid CO2 or liquid N2) is used to cause direct cell injury and cellular freezing. Cryotherapy
Cryogen (liquid CO2 or liquid N2) is used to cause direct cell injury and cellular freezing.
Esophagectomy Patients with high grade dysplasia may need esophagectomy. However with the development of endoscopic techniques surgical treatment is considered a second line treatment option. Surgical resection also carries an increased morbidity and mortality when compared to endoscopic treatment options. Esophagectomy
Patients with high grade dysplasia may need esophagectomy. However with the development of endoscopic techniques surgical treatment is considered a second line treatment option. Surgical resection also carries an increased morbidity and mortality when compared to endoscopic treatment options.

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