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Barrett esophagus

Etiology: 1) chronic irritation of the distal esophagus from refluxed gastric acid & pepsin (GERD) 2) esophageal mucosal damage due to chemotherapy 3) associated with a) long-standing GERD b) large hiatal hernia c) low lower esophageal sphincter pressure d) esophageal dysmotility 4) risk factors - age > 50 years - Caucasian race - central obesity - smoking - family history [21] Epidemiology: 1) occurs in 10% of patients with gastroesophageal reflux 2) overall prevalence 1.6% [6] 3) 2-fold greater prevalence in whites vs non-whites [9] 4) overdiagnosis in 1/3 of patients Pathology: 1) metaplasia of the squamous mucosa in the distal esophagus to a more resistant gastric type (columnar epithelium) 2) adenocarcinoma can arise from Barrett's esophagus - risk is 0.8%/year (a 30-50 fold increased risk) 3) low-grade dysplasia may regress [5] 4) acid facilitates expression of NOX5, associated with increased proliferation, reduced apoptosis Genetics: 1) 17p LOH (p53) predicts progression to adenocarcinoma [6] 2) implicated genes: NOX5 Clinical manifestations: 1) associated with gastroesophageal reflux 2) may occur in association with peptic ulcer disease 3) may be asymptomatic Special laboratory: - upper gastrointestinal endoscopy - proton pump inhibitor prior to endoscopy may improve accuracy of screening [7] - esophageal biopsy (endoscopic muscoal resection) - do not perform biopsy if Z line is normal or has < 1 cm of variability - obtain biopsy prior to endoscopic ablation [2] - use the Prague classification for reporting circumferential & maximal segment length. - if initial screening shows erosive esophagitis, repeat endoscopy after 8-12 weeks of proton-pump inhibitor [21] Radiology: - upper GI series may show stricture in the mid-esophagus Complications: - risk of progression: - increased with duration, dysplasia, male gender [26] - decreased by proton pump inhibitors, statins [26] - increased risk of esophageal carcinoma - HR = 11-30 [14]; 30-50 [2] - absolute risk is 0.12-0.22% per year [14,20] - risk is higher for those with dysplasia at initial biopsy (1.40% vs. 0.17% in those without dysplasia) - most esophageal cancer is diagnosed at the original endoscopy [23] - risk is high inpatients with intestinal metaplasia [11,14] (0.38% vs. 0.07%) - annual risk among US veterans is 0.32% [19] - 80-85% of esophageal adenocarcinoma detected within 1 year of Barrett esophagus diagnosis [25] - if H pylori infection, risk of esophageal carcinoma > gastric carcinoma [30] Management: 1) aggressive management of gastroesophageal reflux - proton pump inhibitor [2,18] - dosage based on symptom relief & healing of erosive esophagitis [2] - does not reduce progression to esophageal cancer [2] - NSAID use may lower risk for esophageal cancer, but does not reduce risk for Barrett esophagus [24] 2) endoscopic surveillance vs endoscopic ablation [2,18] a) dysplasia grade: none-indefinite 1] optimized medical therapy [2] 2] surveillance every 3-5 years [21] or sooner if indefinite [2] 3] discontinue if life-expectany < 1 year or if patient unable to tolerate procedure 4] surveillance may be unnecessary [13] b) dysplasia grade: low 1] surveillance at 6 months & 1 year, then, yearly until age 80 2] radiofrequency ablation is preferable to surveillance if patient is amenable [28] 3] radiofrequency ablation slows progression of low-grade dysplasia [16] c) dysplasia grade: high - radiofrequency ablation rather than surveillance is indicated [16,28] - surveillance every 3 months for 2 years, then every 6 months (if patient refuses ablation) d) high grade dysplasia or adenocarcinoma [31] - endoscopic ablation for patients with high grade dysplasia [2] - combined muscosal resection with ablation of remaining Barrett esophagus is an option [2] - endoscopic ablation if intramucosal cancer [28] - esophagectomy for esophageal cancer if patient is a surgical candidate [2] 3) endocopic surveillance - associated with detection of earlier stage esophageal cancer & may provide a small survival benefit [27] - continue endoscopic surveillance after successful resection of lesions & radiofrequency ablation [28] 4) radiofrequency ablation or photodynamic therapy - endoscopic resection of all visible lesions prior toendoscopic ablation [28] - eradicates metaplasia in 75% ofpatients [2,10] 5) screening - do not routinely screen women with GERD [2,21] - screen men > 50 years with chronic GERD symptoms (> 5 years) & additional risk factors for Barrett esophagus or esophageal cancer [2] - nocturnal reflux, elevated BMI, tobacco use, abdominal fat Notes: - overdiagnosis in 1/3 of patients [17]

Related

esophageal cancer

General

esophagitis metaplasia

Database Correlations

OMIM 109350

References

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  2. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 15, 16, 17, 18, 19. American College of Physicians, Philadelphia 1998, 2006, 2009, 2012, 2015, 2018, 2021. - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  3. Harrison's Principles of Internal Medicine, 13th ed. Isselbacher et al (eds), McGraw-Hill Inc. NY, 1994, pg 1359
  4. Journal Watch 21(2):14, 2001 Macdonald CE et al Final results from 10 year cohort of patients undergoing surveillance for Barrett's oesophagus: observational study. BMJ 321:1252, 2000 PMID: 11082084 - McGarrity TJ Barrett's oesophagus: the continuing conundrum. BMJ 321:1238, 2000 PMID: 11082070
  5. Journal Watch 23(21):167, 2003 Conio M et al Long-term endoscopic surveillance of patients with Barrett's esophagus. Incidence of dysplasia and adenocarcinoma: a prospective study. Am J Gastroenterol 98:1931, 2003 PMID: 14499768 - Sampliner RE Long-term endoscopic surveillance of Barrett's esophagus. Am J Gastroenterol 98:1912, 2003 PMID: 14499764
  6. Ronkainen J et al, Prevalence of Barrett's esophagus in the general population: An endoscopic study. Gastroenterology 2005 129:1825 PMID: 16344051
  7. Hanna S et al, Detection of Barrett's esophagus after endoscopic healing of erosive esophagitis. Am J Gastroenterol 2006, 101:1416 PMID: 16863541
  8. P Sharma. Barrett's Esophagus: Diagnosis and Treatment http://www.medscape.com/viewarticle/463423 - Barrett's Esophagus https://www.niddk.nih.gov/health-information/digestive-diseases/barretts-esophagus
  9. Abrams JA et al, Racial and ethnic disparities in the prevalence of Barrett's esophagus among patients who undergo endoscopy. Clin Gastroenterol Hepatol 2008, 6:30 PMID: 18063419
  10. Shaheen NJ et al, Radiofrequency Ablation in Barrett's Esophagus with Dysplasia NEJM 2009, 360:2277-2288 PMID: 19474425 http://content.nejm.org/cgi/content/short/360/22/2277
  11. Bhat S et al Risk of Malignant Progression in Barrett's Esophagus Patients: Results from a Large Population-Based Study JNCI J Natl Cancer Inst (2011): June 16, 2011 PMID: 21680910 http://jnci.oxfordjournals.org/content/early/2011/06/16/jnci.djr203.abstract - Corley DA Understanding Cancer Incidence in Barrett's Esophagus: Light at the End of the Tunnel NCI J Natl Cancer Inst (2011): June 16, 2011 PMID: 21680911 http://jnci.oxfordjournals.org/content/early/2011/06/16/jnci.djr223.full
  12. Hvid-Jensen F et al Incidence of Adenocarcinoma among Patients with Barrett's Esophagus N Engl J Med 2011; 365:1375-1383October 13, 2011 PMID: 21995385 http://www.nejm.org/doi/full/10.1056/NEJMoa1103042
  13. Corley DA et al. Impact of endoscopic surveillance on mortality from Barrett's esophagus - associated esophageal adenocarcinomas. Gastroenterology 2013 Aug; 145:312. PMID: 23673354
  14. Wang KK, Sampliner RE; Practice Parameters Committee of the American College of Gastroenterology. Updated guidelines 2008 for the diagnosis, surveillance and therapy of Barrett's esophagus. Am J Gastroenterol. 2008 Mar;103(3):788-97 PMID: 18341497
  15. Shaheen NJ, Richter JE. Barrett's oesophagus. Lancet. 2009 Mar 7;373(9666):850-61 PMID: 19269522
  16. Elia J NEJM Journal Watch. March 14, 2014 Massachusetts Medical Society http://www.jwatch.org - Phoa KN et al Radiofrequency Ablation vs Endoscopic Surveillance for Patients With Barrett Esophagus and Low-Grade DysplasiaA Randomized Clinical Trial. JAMA. 2014;311(12):1209-1217 PMID: 24668102 http://jama.jamanetwork.com/article.aspx?articleid=1849991 - Monkemuller K Radiofrequency Ablation for Barrett Esophagus With Confirmed Low-Grade Dysplasia. JAMA. 2014;311(12):1205-1206 PMID: 24668100 http://jama.jamanetwork.com/article.aspx?articleid=1849966
  17. Ganz RA et al. Barrett's esophagus is frequently overdiagnosed in clinical practice: Results of the Barrett's Esophagus Endoscopic Revision (BEER) study. Gastrointest Endosc 2014 Apr; 79:565 PMID: 24262638
  18. Spechler SJ and Souza RF Barrett's Esophagus N Engl J Med 2014; 371:836-84. 5August 28, 2014 PMID: 25162890 http://www.nejm.org/doi/full/10.1056/NEJMra1314704
  19. Shakhatreh MH et al. The incidence of esophageal adenocarcinoma in a national veterans cohort with Barrett's esophagus. Am J Gastroenterol 2014 Dec; 109:1862 PMID: 25331350
  20. Kroep S et al. An accurate cancer incidence in Barrett's esophagus: A best estimate using published data and modeling. Gastroenterology 2015 Sep; 149:577 PMID: 25935635
  21. Shaheen NJ et al. ACG clinical guideline: Diagnosis and management of Barrett's esophagus. Am J Gastroenterol 2015 Nov 3; PMID: 26526079
  22. Spechler SJ, Sharma P, Souza RF et al American Gastroenterological Association technical review on the management of Barrett's esophagus. Gastroenterology. 2011 Mar;140(3):e18-52 PMID: 21376939 - Spechler SJ, Sharma P, Souza RF, Inadomi JM, Shaheen NJ. American Gastroenterological Association medical position statement on the management of Barrett's esophagus. Gastroenterology. 2011 Mar;140(3):1084-91 PMID: 21376940
  23. Visrodia K et al. Magnitude of missed esophageal adenocarcinoma after Barrett's esophagus diagnosis: A systematic review and meta-analysis. Gastroenterology 2016 Mar; 150:599 PMID: 26619962 http://www.gastrojournal.org/article/S0016-5085%2815%2901722-9/abstract
  24. Thrift AP et al. Nonsteroidal anti-inflammatory drug use is not associated with reduced risk of Barrett's esophagus. Am J Gastroenterol 2016 Aug 30 PMID: 27575711
  25. Visrodia K et al. Systematic review with meta-analysis: Prevalent vs. incident oesophageal adenocarcinoma and high-grade dysplasia in Barrett's oesophagus. Aliment Pharmacol Ther 2016 Oct; 44:775. PMID: 27562355
  26. Krishnamoorthi R, Singh S, Ragunathan K et al. Factors associated with progression of Barrett's esophagus: A systematic review and meta-analysis. Clin Gastroenterol Hepatol 2017 Nov 30 PMID: 29199147
  27. Codipilly DC, Chandar AK, Singh S et al. The effect of endoscopic surveillance in patients with Barrett's esophagus: A systematic review and meta-analysis. Gastroenterology 2018 Feb 17 PMID: 29458154 http://www.gastrojournal.org/article/S0016-5085(18)30225-7/pdf
  28. Standards of Practice Committee, Wani S, Qumseya B, Sultan S et al. Endoscopic eradication therapy for patients with Barrett's esophagus-associated dysplasia and intramucosal cancer. Gastrointest Endosc 2018 Apr; 87:907-931.e9. PMID: 29397943
  29. NEJM Knowledge+ Question of the Week. Dec 4, 2018 https://knowledgeplus.nejm.org/question-of-week/397/ - Shaheen NJ, Falk GW, Iyer PG et al. ACG clinical guideline: diagnosis and management of Barrett's esophagus. Am J Gastroenterol 2016 Jan; 111:30. PMID: 26526079
  30. NEJM Knowledge+ Gastroenterology - Spechler SJ, Souza RF. Barrett's esophagus. N Engl J Med. 2014 Aug 28;371(9):836-45. doi: 10.1056/NEJMra1314704. PMID: 25162890 Review. https://www.nejm.org/doi/pdf/10.1056/NEJMra1314704
  31. Sharma P, Shaheen NJ, Katzka D, et al. AGA clinical practice update on endoscopic treatment of Barrett's esophagus with dysplasia and/or early cancer: expert review. Gastroenterology. 2020;158:760-769. PMID: 31730766