Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.
A 55-year-old man is evaluated for a 6-year history of typical gastroesophageal reflux symptoms treated on an as-needed basis with a proton pump inhibitor. However, the frequency of his reflux symptoms has recently increased and his episodes do not respond to treatment as completely as in the past. An upper endoscopy is scheduled to evaluate the cause of this change in his symptoms.
Endoscopy reveals a 4-cm segment of salmon-colored mucosa in the distal esophagus. Biopsy from the salmon-colored segment reveals intestinal metaplasia and goblet cells with no dysplasia.
In addition to starting a daily proton pump inhibitor, which of the following is the most appropriate management?
A: Daily cyclooxygenase-2 (COX-2) inhibitor therapy
B: Endoscopic ablation
C: Fundoplication
D: Repeat endoscopy in 1 year
MKSAP Answer and Critique
The correct answer is D: Repeat endoscopy in 1 year.
This patient should undergo surveillance endoscopy in 1 year for follow-up on pathology findings consistent with Barrett esophagus (BE), which were detected on endoscopy to evaluate his changing reflux symptoms. BE is associated with an increased risk for esophageal adenocarcinoma. If BE is identified on histology, surveillance endoscopy with multiple biopsies should be performed at diagnosis and at 1 year to detect any prevalent dysplasia that was missed on the first endoscopy. If no dysplasia is found, further surveillance can be deferred for 3 years. The presence of low-grade or high-grade dysplasia requires further intensive assessment and management, including the possibility of esophagectomy. The increased risk for malignancy associated with BE has led to screening and surveillance programs, but there is no clear evidence that screening improves survival. Current standards for endoscopic screening in patients with gastroesophageal reflux disease are controversial, but there is some evidence that outcomes may be improved and that it may be cost effective.
Chemoprevention of malignancy with cyclooxygenase-2 (COX-2) inhibitors has been proposed for patients with BE based on studies suggesting an antiproliferative effect on BE-associated tumor cells. However, the effectiveness of this potential therapy has not been established.
Endoscopic ablation is currently not recommended in patients with nondysplastic BE, because the procedure carries risks, and the benefits of ablation do not appear to exceed the risk of progression to adenocarcinoma (0.5% per year). Ablative therapies that consist of removal of metaplastic epithelium can, when combined with intensive acid suppression therapy, lead to the regeneration of squamous mucosa. Concerns remain that areas of abnormal mucosa below the normal-appearing regenerated epithelium may still harbor cancer risk.
Surgical fundoplication is considered in patients with reflux symptoms refractory to medical therapy. However, it has not been shown to decrease the risk of cancer in patients with BE.
Key Point
- Patients with Barrett esophagus should undergo endoscopic surveillance to monitor for progression of dysplasia.
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