BARRETT ESOPHAGUS Gastroenterology Vousrse

Barret esophagus GOT

1. BARRETT ESOPHAGUS Made by: Mustafa Al-tawil Group: 918-b

2. OUTLINES: Definition Pathophysiology Epidemiology Symptoms Complications Diagnosis Classification Differential Diagnosis Treatment Prevention Prognosis References

3. DEFINITION: Is the replacement of healthy esophageal stratified squamous epithelium with metaplastic columnar cells, because of the damage from prolonged exposure of the esophagus to the gastric acidity due to the gastroesophageal reflux disease (GERD).

4. PATHOPHYSIOLOGY: Prolonged exposure of the esophagus to the refluxate of GERD can erode the esophageal mucosa, promote inflammatory cell infiltrate, and ultimately cause epithelial necrosis. This chronic damage is believed to promote the replacement of healthy esophageal stratified squamous epithelium with the metaplastic columnar cells of Barrett esophagus.

5. EPIDEMIOLOGY: The average age of patients with Barrett esophagus is 55-65 years . The condition occurs in a 3:1 male-to-female ratio, with white males making up more than 80% of cases. Some studies indicate a higher prevalence of smoking, alcohol intake, and obesity in persons with the disease. Estimates of the prevalence of Barrett esophagus vary considerably and range from 0.9-10% of the general adult population. Thrift AP. Determination of risk for Barrett's esophagus and esophageal adenocarcinoma. Curr Opin Gastroenterol. 2016 Jul. 32(4):319-24. [QxMD MEDLINE Link]. Schmidt M, Ankerst DP, Chen Y, et al. Epidemiologic risk factors in a comparison of a Barrett esophagus registry (BarrettNET) and a case-control population in Germany. Cancer Prev Res (Phila). 2020 Apr. 13(4):377-84. [QxMD MEDLINE Link]. [Full Text].

6. SYMPTOMS: No unique physical examination characteristics are evident in patients with Barrett esophagus other than those that would be found in patients with chronic GERD .

7. COMPLICATIONS: The development of adenocarcinoma in the esophagus. However, most patients with Barrett esophagus will not develop esophageal cancer, with the risk of progression to adenocarcinoma of the esophagus being estimated at approximately 0.5% per year in patients without dysplasia on initial surveillance biopsies.

8. DIAGNOSIS: Esophagogastroduodenoscopy (EGD) : is the procedure of choice for the diagnosis of Barrett esophagus. The diagnosis requires biopsy confirmation of specialized intestinal metaplasia in the esophagus. (In cases of erosive esophagitis, a healing of the mucosa is required prior to EGD to ensure a lack of Barrett mucosa underneath the inflammation). Histological findings of Barrett esophagus . When high-grade dysplasia or cancer is found on surveillance endoscopy, endoscopic ultrasonography (EUS) is advisable to evaluate for surgical resectability. Sharma P, Falk GW, Bhor M, et al. Real-world upper endoscopy utilization patterns among patients with gastroesophageal reflux disease, Barrett esophagus, and Barrett esophagus-related esophageal neoplasia in the United States. Medicine (Baltimore). 2023 Mar 24. 102(12):e33072. [QxMD MEDLINE Link]. [Full Text].

9. CLASSIFICATION:

10. DIFFERENTIAL DIAGNOSIS: Esophageal adenocarcinoma must be differentiated from other causes of dysphagia, odynophagia and food regurgitation such as: GERD esophageal stricture reflux esophagitis systemic sclerosis esophageal spasm Pseudo-achalasia esophageal candidiasis

11. TREATMENT: Medication therapy: Currently, the indications for medical therapy in Barrett esophagus control of symptoms and healing of esophageal mucosa are the same as those for GERD . An important question is whether abolishing acid completely with high-dose PPIs decreases the risk for adenocarcinoma of the esophagus is worth the cost and possible adverse effects of this therapy or we can use H2-receptor antagonists instead ?

12. TREATMENT: Surgical therapy: No evidence that surgery causes regression of Barrett esophagus. Although regression of features associated with cancer risk are more common following surgical intervention than medical therapy. The gold standard is endoscopic ablation procedure .

13. TREATMENT: Types of endoscopic ablation are: Radiofrequency ablation: is a balloon-based, bipolar radiofrequency ablation system. Photodynamic therapy: involves the use of a photosensitizing agent (typically, a hematoporphyrin because it has a greater affinity for neoplastic tissue) that accumulates in tissue and induces local necrosis through the production of intracellular free radicals following exposure to light at a certain wavelength. Argon plasma coagulation (APC) ablation: is a method of contact-free high-frequency current coagulation in which the burning of tissue stops as soon as the area is ablated. Multipolar electrocoagulation (MPEC) ablation: ablation by direct contact with an electrocautery probe.

14. TREATMENT: Predictors of recurrence were increasing age and length of Barrett esophagus. Incidence rates of recurrence (per patient year) included the following: Dysplastic Barrett esophagus: 2.0% for radiofrequency ablation; 1.3% for endoscopic therapy. High-grade dysplasia/esophageal adenocarcinoma: 1.2%for radiofrequency ablation; 0.8% for endoscopic therapy.

15. TREATMENT: Diet: ( same as the diet that is given for GERD patients). Patients should avoid the following; Fried or fatty foods Chocolate Peppermint Alcohol Coffee Carbonated beverages Citrus fruits or juices Tomato sauce Ketchup Vinegar Aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs)

16. Rayner CJ, Gatenby P. Effect of antireflux surgery for Barrett's esophagus: long-term results. Minerva Chir. 2016 Jun. 71(3):180-91. [QxMD MEDLINE Link]. Krishnamoorthi R, Singh S, Ragunathan K, A Katzka D, K Wang K, G Iyer P. Risk of recurrence of Barrett's esophagus after successful endoscopic therapy. Gastrointest Endosc. 2016 Jun. 83(6):1090-1106.e3. [QxMD MEDLINE Link]. Zhao Z, Pu Z, Yin Z, et al. Dietary fruit, vegetable, fat, and red and processed meat intakes and Barrett's esophagus risk: a systematic review and meta-analysis. Sci Rep. 2016 Jun 3. 6:27334. [QxMD MEDLINE Link]. Prasad GA, Wang KK, Buttar NS, et al. Long-term survival following endoscopic and surgical treatment of high-grade dysplasia in Barrett's esophagus. Gastroenterology. 2007 Apr. 132(4):1226-33. [QxMD MEDLINE Link]. Brown T. Barrett's esophagus: endoluminal therapy safe, effective. Medscape Medical News. February 15, 2013. Available at https://www.medscape.com/viewarticle/779427. Accessed: March 11, 2013. Guarner-Argente C, Buoncristiano T, Furth EE, Falk GW, Ginsberg GG. Long-term outcomes of patients with Barrett's esophagus and high-grade dysplasia or early cancer treated with endoluminal therapies with intention to complete eradication. Gastrointest Endosc. 2013 Feb. 77(2):190-9. [QxMD MEDLINE Link]. Nayna L, Emma W, Vani K. Radiofrequency ablation for low-grade dysplasia in Barrett's esophagus. Curr Opin Gastroenterol. 2016 Jul. 32(4):294-301. [QxMD MEDLINE Link]. Shaheen NJ, Sharma P, Overholt BF, et al. Radiofrequency ablation in Barrett's esophagus with dysplasia. N Engl J Med. 2009 May 28. 360(22):2277-88. [QxMD MEDLINE Link]. [Full Text]. Sampliner RE, Fennerty B, Garewal HS. Reversal of Barrett's esophagus with acid suppression and multipolar electrocoagulation: preliminary results. Gastrointest Endosc. 1996 Nov. 44(5):532-5. [QxMD MEDLINE Link]. Allison H, Banchs MA, Bonis PA, Guelrud M. Long-term remission of nondysplastic Barrett's esophagus after multipolar electrocoagulation ablation: report of 139 patients with 10 years of follow-up. Gastrointest Endosc. 2011 Apr. 73(4):651-8. [QxMD MEDLINE Link].

17. PREVENTION: Avoid smoking and chewing tobacco. Avoid drinking alcohol. Maintain a healthy body weight. Avoid food that trigger GERD symptoms. Sleeping with your head slightly elevated. Diet with fruits and vegetables rich in vitamins.

18. PROGNOSIS: The most significant morbidity associated with Barrett esophagus is the development of adenocarcinoma in the esophagus. However, most patients with Barrett esophagus will not develop esophageal cancer, with the risk of progression to adenocarcinoma of the esophagus being estimated at approximately 0.5% per year in patients without dysplasia on initial surveillance biopsies.

19. 1. Which of the following is a risk factor for developing Barrett’s esophagus? Chronic gastroesophageal reflux disease (GERD). B) High-fiber diet. C) Low body mass index (BMI). D) Smoking cessation.

20. 2. What is the hallmark histological feature of Barrett’s esophagus? A) Squamous epithelium replaced by columnar epithelium. B) Inflammation of the submucosa. C) Presence of dysplastic cells in the epithelium. D) Erosion of the mucosal surface.

21. 3. Which of the following is a common complication of Barrett’s esophagus? A) Esophageal varices. B) Esophageal adenocarcinoma. C) Achalasia. D) Esophageal spasm.

22. 4. What is the primary treatment approach for Barrett’s esophagus with dysplasia? Proton pump inhibitors (PPIs). B) Endoscopic mucosal resection or ablation. C) Chemotherapy. D) Lifestyle modifications and dietary changes.

23. 5. Which of the following screening techniques is commonly used to monitor Barrett’s esophagus? Barium swallow. B) Endoscopy with biopsy. C) Chest X-ray. D) Esophageal manometry.

24. ANSWERS: A) Chronic gastroesophageal reflux disease (GERD). A) Squamous epithelium replaced by columnar epithelium B) Esophageal adenocarcinoma B) Endoscopic mucosal resection or ablation B) Endoscopy with biopsy

25. REFERANCES: https://emedicine.medscape.com/article/171002-overview