Core IM: 5 Pearls on Barrett’s Esophagus

January 30, 2019

By Vishal Shah MD, Milna Rufin MD, Marty Fried MD, Shreya P. Trivedi MD || Illustration by Amy Ou MD || Audio Editing by Harit Shah. Quiz yourself on the 5 Pearls we will be covering:

  • What is Barrett’s esophagus? (4:12)
  • Who do we screen for Barrett’s, and why? (8:41)
  • How do we screen for Barrett’s and counsel? (13:50)
  • How do we treat and monitor Barrett’s esophagus? (18:21)
  • Take Aways (21:45)
  • Throwback to trending troponins (23:05)

Thank you to peer-reviewers Dr. Nicholas Shaheen, Dr. David Katzka, and Dr. Joe Kingsbery.

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Show Notes

Pearl 1: What is Barrett’s esophagus?

  • Barrett’s esophagus is metaplasia of the normal squamous epithelium of the esophagus to columnar epithelium.
  • Estimated prevalence of Barrett’s in the general population is 5%, and the majority have do not have dysplasia, but if there is high grade dysplasia, there is a 7% annual risk of developing adenocarcinoma, which is what we ultimately want to prevent.

Pearl 2: Who do we screen for Barrett’s, and why?

  • According to the American College of Gastroenterology (ACG), we should screen men who have chronic GERD and have at least two risk factors: Caucasian race, age over 50 years, any smoking history, central obesity, or a 1 relative with barrett’s or esophageal adenocarcinoma.

Pearl 3: How do we screen for Barrett’s and counsel if they do have Barrett’s?

  • Screening is done with an upper endoscopy (EGD) with 8 biopsies and is specially reviewed by expert pathologists.
  • The majority of patients with Barrett’s will have the nondysplastic type. Per Dr. Shaheen, it should be phrased to the patient as, “This is a chronic disease like any other chronic disease, diabetes, hypertension, etc. We check certain parameters to make sure that you’re not having your disease worsen, you should think about this. The overall risk of progression is quite low.” 

Pearl 4: How do we treat and monitor Barrett’s esophagus?

  • Patients with Barrett’s esophagus should be on a once daily PPI because of its chemoprotective nature, even in the absence of GERD symptoms.
  • Patients with nondysplastic Barrett’s should be reassured that there is low rate of progression, and should have repeat EGD every 3-5 years for surveillance.
  • If there is low grade dysplasia, the patient can choice between surveillance with more frequent EGDs or radiofrequency ablation.
  • If there is high grade dysplasia, first-line treatment is radiofrequency ablation followed by routine surveillance.

Pearl 5: Throwback to trending troponins

  • The delta, or change in between the two values of troponin, can help guide suspicion for ACS in less clear cases.