Barrett Esophagus with Case

00:01 We'll move on to our next case. We have 73-year-old man seen in clinic for follow-up of his GERD.

00:07 He has had heartburn for the last 15 years.

00:10 Previously well controlled on pantoprazole.

00:12 In the last few weeks, he has noticed worsened symptoms and a sour taste in his mouth despite taking his pantoprazole as directed.

00:20 He has no dysphagia, weight loss, or vomiting. Vitals are normal.

00:25 Exam is unremarkable.

00:26 His upper endoscopy shows a small hiatal hernia and dark, pink-colored mucosa in the distal esophagus.

00:33 Biopsies are taken that show columnar epithelium with high-grade dysplasia.

00:39 So what is the best next step in management? Let's look at some key features here.

00:44 He has longstanding GERD for the last 15 years, he has worsening symptoms despite appropriate therapy, and luckily, he has no alarm symptoms of dysphagia, weight loss, or vomiting.

00:58 However, his endoscopy has some suspicious findings on it that we'll talk about in a bit.

01:04 So let's talk about Barret esophagus.

01:08 This is when normal squamous epithelium in the distal esophagus is replaced by a metaplastic columnar epithelium.

01:16 It often has this gross appearance on endoscopy showing here at the right where you can see a clear transition between salmon-colored mucosa to the normal esophageal mucosa.

01:27 Some of the risk factors include older age, male gender, white ethnicity, GERD, hiatal hernias, obesity, and smoking.

01:38 This an important condition to recognize because it is pre-malignant that has a small per year risk of progressing to esophageal adenocarcinoma.

01:49 The diagnosis must be made by upper endoscopy and then taking biopsies to examine histology.

01:56 Treatment is with a twice-daily proton pump inhibitor and if the patient has high-grade dysplasia on their biopsy performing endoscopic ablation.

02:07 So now we'll go back to our case.

02:11 We have a 73-year-old man with longstanding GERD, worsening symptoms despite appropriate therapy, no alarm symptoms, but these suspicious findings on his endoscopy.

02:22 So this appearance of pink-colored mucosa in the distal esophagus with columnar epithelium should prompt you to think of Barret esophagus.

02:32 Because he has high-grade dysplasia, the best next step involves endoscopic ablation to prevent progression to cancer.