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Essential Features

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  • • Gastroesophageal reflux disease (GERD)

    • Metaplastic changes from squamous to intestinal-type columnar epithelium in the distal esophagus

    • Metaplasia may contain varying degrees of dysplasia, which is associated with increasing risk of developing esophageal adenocarcinoma

    • Neither medical nor surgical treatment consistently causes regression of metaplastic changes but may prevent progression

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Epidemiology

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  • • Acquired intestinal-type metaplasia of any length that replaces the normal squamous epithelium of the distal esophagus; induced by chronic gastroesophageal reflux

    • Found in 10–20% of patients with gastroesophageal reflux

    • Male:female incidence of 2:1; increasing incidence with increased age

    • Conveys a 2-fold increased risk of developing adenocarcinoma

    • Adenocarcinoma is found in 10% of patients with Barrett epithelium at the time of first endoscopic exam

    • Lower esophageal sphincter pressure averages 5 mm Hg; 24-hour pH monitoring reveals increased esophageal acid exposure and impaired clearing

    • Reflux of bile acids may contribute to the development of Barrett esophagus along with acid and pepsin

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Clinical Findings

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Symptoms and Signs

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  • • Heartburn, milder than in the absence of Barrett changes because the metaplastic epithelium is less sensitive than squamous epithelium

    • Regurgitation

    • Dysphagia

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Imaging Findings

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  • Esophagoscopy: Pink epithelium in the lower esophagus instead of the shiny gray-pink squamous mucosa; must be verified by biopsy

    Contrast radiography: Hiatal hernia, esophageal stricture, or ulcer

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Diagnostic Considerations

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  • • Patients with moderate to severe GERD should undergo endoscopy and biopsy to assess distal esophagus for metaplastic changes

    • Only biopsy proven intestinal-type metaplasia is associated with increased risk of adenocarcinoma

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Rule Out

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  • • High-grade dysplasia

    • Adenocarcinoma

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Work-up

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  • • Esophagoscopy and biopsy

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Treatment and Management

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  • • Treatment is the same as for GERD

    • Surgical treatment is fundoplication

    • Metaplastic epithelium rarely regresses after medical or surgical therapy

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Surgery

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Indications
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  • • Severe GERD refractory to medical treatment

    • Esophageal strictures and ulcers

    • Esophagectomy for high-grade dysplasia

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Medications

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  • • H2-blocking agents

    • Proton pump inhibitors

    • Antacids

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Treatment Monitoring

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  • • Routine endoscopy and biopsy should be performed every 6–12 months to assess degree of dysplasia

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Complications

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  • • Esophageal ulcer

    • Esophageal stricture

    • Esophageal adenocarcinoma

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Prognosis

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  • • Estimated incidence of adenocarcinoma in patients with Barrett esophagus of 1:100 patient years of follow-up

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Prevention

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  • • Aggressive treatment of GERD

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Resources

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References

Chang LC et al: Long-term outcome of esophagectomy for high grade dysplasia or cancer found during surveillance for ...

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