Gastroenterology · Esophageal Disorders
The facts most likely to be tested
Barrett esophagus is defined by the metaplastic replacement of normal squamous epithelium with columnar epithelium containing goblet cells in the distal esophagus.
Chronic gastroesophageal reflux disease (GERD) is the primary risk factor for the development of Barrett esophagus.
The gold standard for diagnosis is upper endoscopy (EGD) with biopsy showing intestinal metaplasia.
Patients with Barrett esophagus are at significantly increased risk for developing esophageal adenocarcinoma.
Surveillance for non-dysplastic Barrett esophagus is performed via periodic endoscopy to monitor for the progression to dysplasia.
The presence of high-grade dysplasia in Barrett esophagus is an indication for endoscopic eradication therapy such as radiofrequency ablation.
The Seattle protocol requires four-quadrant biopsies every 1–2 cm of the affected segment to ensure adequate sampling for dysplasia.
Vignette unlocked
A 58-year-old male with a 15-year history of chronic heartburn and regurgitation presents for a follow-up evaluation. He reports taking over-the-counter omeprazole daily with partial relief. On physical examination, he is obese with a BMI of 32 kg/m². An upper endoscopy is performed, revealing a velvety, salmon-colored mucosa extending 4 cm proximal to the gastroesophageal junction. Biopsy of this area confirms the presence of goblet cells.
What is the most appropriate long-term management strategy for this patient?
Periodic endoscopic surveillance with biopsies
The patient has confirmed Barrett esophagus; the standard of care for non-dysplastic Barrett esophagus is periodic endoscopic surveillance to detect progression to dysplasia.
Full handout
High yield triage
Etiology / Epidemiology
Chronic GERD is the primary driver; affects Caucasian males >50 years old.
Clinical Manifestations
Often asymptomatic; classic heartburn and dysphagia are common.
Diagnosis
Upper endoscopy with biopsy is the gold standard; look for columnar metaplasia.
Treatment
Proton pump inhibitors (PPIs) are first-line; do not ignore alarm symptoms.
Prognosis
Precursor to esophageal adenocarcinoma; requires surveillance endoscopy.
Full handout
Epidemiology & Etiology
Strongly associated with long-standing GERD and hiatal hernia. Predominantly affects Caucasian males over age 50. Obesity and smoking are significant independent risk factors.
Pertinent Anatomy
Involves the distal esophagus where the normal squamous epithelium is replaced by columnar epithelium with goblet cells. This transition occurs at the gastroesophageal junction.
Pathophysiology
Chronic acid exposure causes metaplasia of the esophageal lining to protect against gastric acid. This process progresses from low-grade dysplasia to high-grade dysplasia. Ultimately, this leads to the development of esophageal adenocarcinoma.
Clinical Manifestations
Patients often present with chronic heartburn or acid regurgitation. Alarm symptoms include unintentional weight loss, odynophagia, or iron deficiency anemia, which suggest malignant transformation. Many patients are diagnosed incidentally during workup for dysphagia.
Diagnosis
Upper endoscopy (EGD) is the gold standard for diagnosis. Biopsy must confirm intestinal metaplasia (presence of goblet cells). Surveillance intervals are determined by the degree of dysplasia found on histology.
Treatment
Long-term Proton pump inhibitors (PPIs) are the first-line therapy to control acid reflux. Avoid NSAIDs if erosive esophagitis is present. For high-grade dysplasia, endoscopic mucosal resection or radiofrequency ablation is indicated.
Prognosis
The primary concern is the progression to esophageal adenocarcinoma. Patients require periodic surveillance endoscopy to monitor for malignant changes. The risk of cancer is significantly higher in patients with confirmed dysplasia.
Differential Diagnosis
GERD: lacks histological evidence of intestinal metaplasia
Eosinophilic Esophagitis: characterized by dysphagia and rings/furrows on endoscopy
Esophageal Adenocarcinoma: presents with rapid weight loss and obstructive symptoms
Peptic Stricture: presents with progressive solid food dysphagia
Infectious Esophagitis: typically seen in immunocompromised patients with odynophagia