Barrett esophagus
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[1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31]
Etiology
- chronic irritation of the distal esophagus from refluxed gastric acid & pepsin (GERD)
- esophageal mucosal damage due to chemotherapy
- associated with
- long-standing GERD
- large hiatal hernia
- low lower esophageal sphincter pressure
- esophageal dysmotility
- risk factors
Epidemiology
- occurs in 10% of patients with gastroesophageal reflux
- overall prevalence 1.6%[6]
- 2-fold greater prevalence in whites vs non-whites[9]
- overdiagnosis in 1/3 of patients
Pathology
- metaplasia of the squamous mucosa in the distal esophagus to a more resistant gastric type (columnar epithelium)
- adenocarcinoma can arise from Barrett's esophagus
- risk is 0.8%/year (a 30-50 fold increased risk)
- low-grade dysplasia may regress[5]
- acid facilitates expression of NOX5, associated with increased proliferation, reduced apoptosis
Genetics
Clinical manifestations
- associated with gastroesophageal reflux
- may occur in association with peptic ulcer disease
- may be asymptomatic
Diagnostic procedures
- 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 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
- 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]
- proton pump inhibitor[2][18]
- endoscopic surveillance vs endoscopic ablation[2][18]
- dysplasia grade: none-indefinite
- dysplasia grade: low
- surveillance at 6 months & 1 year, then, yearly until age 80
- radiofrequency ablation is preferable to surveillance if patient is amenable[28]
- radiofrequency ablation slows progression of low-grade dysplasia[16]
- 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)
- radiofrequency ablation rather than surveillance is indicated[16][28]
- high grade dysplasia or adenocarcinoma[31]
- endoscopic ablation for patients with high grade dysplasia[2]
- endoscopic ablation if intramucosal cancer[28]
- esophagectomy for esophageal cancer if patient is a surgical candidate[2]
- 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]
- radiofrequency ablation or photodynamic therapy
- endoscopic resection of all visible lesions prior toendoscopic ablation[28]
- eradicates metaplasia in 75% ofpatients[2][10]
- screening
Notes
- overdiagnosis in 1/3 of patients[17]
More general terms
Additional terms
References
- ↑ Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 280
- ↑ 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 2.13 2.14 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 - ↑ Harrison's Principles of Internal Medicine, 13th ed. Isselbacher et al (eds), McGraw-Hill Inc. NY, 1994, pg 1359
- ↑ 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: https://www.ncbi.nlm.nih.gov/pubmed/11082084
McGarrity TJ Barrett's oesophagus: the continuing conundrum. BMJ 321:1238, 2000 PMID: https://www.ncbi.nlm.nih.gov/pubmed/11082070 - ↑ 5.0 5.1 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: https://www.ncbi.nlm.nih.gov/pubmed/14499768
Sampliner RE Long-term endoscopic surveillance of Barrett's esophagus. Am J Gastroenterol 98:1912, 2003 PMID: https://www.ncbi.nlm.nih.gov/pubmed/14499764 - ↑ 6.0 6.1 6.2 Ronkainen J et al, Prevalence of Barrett's esophagus in the general population: An endoscopic study. Gastroenterology 2005 129:1825 PMID: https://www.ncbi.nlm.nih.gov/pubmed/16344051
- ↑ 7.0 7.1 Hanna S et al, Detection of Barrett's esophagus after endoscopic healing of erosive esophagitis. Am J Gastroenterol 2006, 101:1416 PMID: https://www.ncbi.nlm.nih.gov/pubmed/16863541
- ↑ 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 - ↑ 9.0 9.1 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: https://www.ncbi.nlm.nih.gov/pubmed/18063419
- ↑ 10.0 10.1 Shaheen NJ et al, Radiofrequency Ablation in Barrett's Esophagus with Dysplasia NEJM 2009, 360:2277-2288 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/19474425 <Internet> http://content.nejm.org/cgi/content/short/360/22/2277
- ↑ 11.0 11.1 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 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/21680910 <Internet> 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 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/21680911 <Internet> http://jnci.oxfordjournals.org/content/early/2011/06/16/jnci.djr223.full - ↑ Hvid-Jensen F et al Incidence of Adenocarcinoma among Patients with Barrett's Esophagus N Engl J Med 2011; 365:1375-1383October 13, 2011 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/21995385 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMoa1103042
- ↑ 13.0 13.1 Corley DA et al. Impact of endoscopic surveillance on mortality from Barrett's esophagus - associated esophageal adenocarcinomas. Gastroenterology 2013 Aug; 145:312. PMID: https://www.ncbi.nlm.nih.gov/pubmed/23673354
- ↑ 14.0 14.1 14.2 14.3 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: https://www.ncbi.nlm.nih.gov/pubmed/18341497
- ↑ Shaheen NJ, Richter JE. Barrett's oesophagus. Lancet. 2009 Mar 7;373(9666):850-61 PMID: https://www.ncbi.nlm.nih.gov/pubmed/19269522
- ↑ 16.0 16.1 16.2 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 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/24668102 <Internet> 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 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/24668100 <Internet> http://jama.jamanetwork.com/article.aspx?articleid=1849966 - ↑ 17.0 17.1 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: https://www.ncbi.nlm.nih.gov/pubmed/24262638
- ↑ 18.0 18.1 18.2 Spechler SJ and Souza RF Barrett's Esophagus N Engl J Med 2014; 371:836-84. 5August 28, 2014 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/25162890 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMra1314704
- ↑ 19.0 19.1 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: https://www.ncbi.nlm.nih.gov/pubmed/25331350
- ↑ 20.0 20.1 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: https://www.ncbi.nlm.nih.gov/pubmed/25935635
- ↑ 21.0 21.1 21.2 21.3 21.4 Shaheen NJ et al. ACG clinical guideline: Diagnosis and management of Barrett's esophagus. Am J Gastroenterol 2015 Nov 3; PMID: https://www.ncbi.nlm.nih.gov/pubmed/26526079
- ↑ 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: https://www.ncbi.nlm.nih.gov/pubmed/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: https://www.ncbi.nlm.nih.gov/pubmed/21376940 - ↑ 23.0 23.1 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 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/26619962 <Internet> http://www.gastrojournal.org/article/S0016-5085%2815%2901722-9/abstract
- ↑ 24.0 24.1 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: https://www.ncbi.nlm.nih.gov/pubmed/27575711
- ↑ 25.0 25.1 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: https://www.ncbi.nlm.nih.gov/pubmed/27562355
- ↑ 26.0 26.1 26.2 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: https://www.ncbi.nlm.nih.gov/pubmed/29199147
- ↑ 27.0 27.1 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 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/29458154 <Internet> http://www.gastrojournal.org/article/S0016-5085(18)30225-7/pdf
- ↑ 28.0 28.1 28.2 28.3 28.4 28.5 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: https://www.ncbi.nlm.nih.gov/pubmed/29397943
- ↑ 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: https://www.ncbi.nlm.nih.gov/pubmed/26526079 - ↑ 30.0 30.1 NEJM Knowledge+ Gastroenterology
Spechler SJ, Souza RF. Barrett's esophagus. N Engl J Med. 2014 Aug 28;371(9):836-45. doi:http://dx.doi.org/ 10.1056/NEJMra1314704. PMID: https://www.ncbi.nlm.nih.gov/pubmed/25162890 Review. https://www.nejm.org/doi/pdf/10.1056/NEJMra1314704 - ↑ 31.0 31.1 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: https://www.ncbi.nlm.nih.gov/pubmed/31730766
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