A 65-year-old man is evaluated with upper endoscopy in follow-up for Barrett esophagus. He has had heartburn for more than 15 years, but his symptoms have been well controlled with daily omeprazole. He reports no weight loss or pain with swallowing and has no history of anemia. He stopped smoking 5 years earlier, but has a 40-pack-year history.
Vital signs and the remainder of the physical examination are normal.
On upper endoscopy, an area of salmon-colored mucosa is seen in the esophagus. Biopsies confirm evidence of Barrett esophagus with low-grade dysplasia. The pathology slides were reviewed by a second pathologist, confirming the presence of low-grade dysplasia.
Which of the following is the most appropriate next step in management?
A. Endoscopic ablation
D. Repeat endoscopy in 6 months
MKSAP Answer and Critique
The correct answer is A. Endoscopic ablation. This content is available to MKSAP 18 subscribers as Question 63 in the Gastroenterology and Hepatology section. More information about MKSAP is available online.
Endoscopic ablation therapy is the most appropriate next step in the management of this patient's Barrett esophagus with low-grade dysplasia. Barrett esophagus is a consequence of chronic reflux, regardless of the presence of gastroesophageal reflux disease (GERD) symptoms. The damage from GERD causes a change in the normal squamous lining of the distal esophagus to a specialized columnar epithelium visible on endoscopy. Barrett esophagus can present with no dysplasia, indefinite dysplasia, low-grade dysplasia, or high-grade dysplasia, and in some patients dysplasia progresses to adenocarcinoma of the esophagus. In the past, guidelines recommended a surveillance endoscopy in 6 months for patients with low-grade dysplasia. However, more recent guidelines recommend that patients with minimal comorbidities undergo endoscopic ablation therapy for permanent eradication of Barrett esophagus.
Endoscopic ablation should be considered after confirmation of dysplasia by a second expert pathologist. If a patient is ineligible for or unwilling to undergo ablation therapy, annual surveillance endoscopy is recommended as an alternative. If two consecutive surveillance endoscopies show no dysplasia, the surveillance interval is changed to every 3 to 5 years, the same interval used in patients with Barrett esophagus with no dysplasia. Patients with Barrett esophagus with high-grade dysplasia are also treated with endoscopic ablation.
Esophagectomy is reserved for patients in whom ablation does not result in eradication of the dysplasia or who have esophageal cancer.
Surgical treatments for GERD consist of laparoscopic fundoplication, an endoscopic procedure that does not cure Barrett esophagus or reduce the risk for progression of dysplasia or cancer, and bariatric surgery (for patients with obesity). Indications for surgery include patient preference to stop taking medication, medication side effects, large hiatal hernia, and refractory symptoms despite maximal medical therapy (although patients with medically refractory symptoms may be less likely to benefit from surgery). Approximately one third of patients require resumption of PPI therapy within 5 to 10 years after surgery. Postoperative complications include dysphagia, diarrhea, and inability to belch because of a tight fundoplication.
Guidelines recommend that patients with Barrett esophagus undergo surveillance only after adequate counseling regarding the risks and benefits of surveillance. Patients with nondysplastic Barrett esophagus should undergo endoscopic surveillance no more frequently than every 3 to 5 years.
- Barrett esophagus with low-grade dysplasia should be treated with endoscopic ablation therapy in patients without significant comorbidities.