Barrett's Esophagus and Esophageal Adenocarcinoma
Barrett's esophagus is a premalignant condition related to chronic GERD. The hallmark is a change in the mucosal lining of the distal esophagus from the normal squamous epithelium to columnar-appearing mucosa resembling that of the stomach and small intestines, referred to as intestinal metaplasia (Fig. 38-4). The estimated risk of progression to adenocarcinoma of the esophagus with Barrett's esophagus is approximately 0.5% per year, whereas without Barrett's esophagus the risk is 0.07%, prompting development of clinical practice guidelines for surveillance endoscopy.
Adenocarcinoma of the esophagus has had the fastest-rising incidence of any cancer in the United States and Western Europe over the last two decades. Family and other primary care physicians who see the vast majority of patients with GERD in its nonerosive and more complicated forms are charged with the task of suspecting and appropriately referring patients with Barrett's esophagus for EGD. Although risk factors for Barrett's esophagus and adenocarcinoma are not evidence-based, there is suggestive evidence that male gender, white race, older age, dysplasia, smoking, and obesity place patients at a higher risk (Sampliner, 2002).
Currently, no evidence-based guidelines exist for the assessment and surveillance of patients with Barrett's esophagus; routine screening will not be cost-effective unless criteria can be identified to select patients at high risk. Recommendations from the American Society for Gastrointestinal Endoscopy
(ASGE) state that screening esophagogastroduodenoscopy (EGD) for Barrett's esophagus should be considered in select patients with chronic, long-standing GERD. After a negative screening examination, further screening endoscopy is not indicated. For patients with established Barrett's esophagus of any length and with no dysplasia, after two consecutive examinations within 1 year, an acceptable interval for additional surveillance is every 3 years. Surveillance in patients with low-grade dysplasia is recommended, although the optimal interval and biopsy protocol have not been established. A follow-up EGD at 6 months should be performed, and if low-grade dysplasia is confirmed, surveillance at 12 months and yearly thereafter as long as dysplasia persists is advised (Hirota et al., 2006).
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Gastroesophageal reflux disease is the medical term for what we know as acid reflux. Acid reflux occurs when the stomach releases its liquid back into the esophagus, causing inflammation and damage to the esophageal lining. The regurgitated acid most often consists of a few compoundsbr acid, bile, and pepsin.