Barrett's Esophagus: Diagnosis, Treatment, and Management Tips

Barrett's esophagus

Hello, Doctor.
Below is my esophagogastroduodenoscopy (EGD) pathology report.
Report of EGD
Esophagus: A shallow ulcer noted at the esophagogastric (EG) junction, s/p biopsy *1 for pathology.
Mucosal break less than 5mm noted at the EG junction.

Stomach: Esophagogastric flap valve (EGFV) type I (Hill's classification)
- Cardia and fundus: negative
- Angle: negative
- Body: negative
- Antrum: hyperemia noted, s/p self-paid CLO test
Duodenum: Negative for the bulb and 2nd portion.
Diagnostic Impression
1.
Esophageal ulcers, EG junction, s/p biopsy
2.
Gastroesophageal reflux disease (GERD), LA grade A
3.
Superficial gastritis, antrum, s/p self-paid CLO test
Suggestion of Management
PPI therapy
CLO Test Report: Negative (-)
Pathology Report: Labeled as EG junction, anastomosis site, biopsy, chronic inflammation with ulcer and intestinal metaplasia.

Description: The specimen submitted consists of a tissue fragment measuring 0.2*0.1*0.1 cm in size fixed in formalin.
Grossly, it is tan and elastic.
All for section.
Microscopically, the section shows gastric mucosa only, revealing ulcer with inflammatory exudate and mixed acute and chronic inflammatory cell infiltration.
Areas of intestinal metaplasia are noted as well.
No squamous epithelium is included.
Combined with clinical information, Barrett's esophagus with ulcer might be considered.
Please correlate with clinical presentation.
Gastroesophageal reflux and gastritis have troubled me for over ten years, and in recent years, it has become increasingly severe.
I have a few questions I would like to ask you:
1.
Has the above EGD examination confirmed "Barrett's esophagus"? I see the term "intestinal metaplasia," but I am unsure of its exact meaning and severity.

2.
I have been taking the PPI medication "Dexilant" for over three months, and my symptoms have only slightly improved.
How long should I continue taking the medication? (I have severe osteoporosis, with a T-score of -3.4, and I am concerned that PPI medication may affect calcium absorption.)
3.
When should I undergo another EGD?
4.
Is there a need for a "24-hour pH monitoring test"? Currently, my symptoms include a frequent feeling of pressure in the chest, belching, bloating, occasional dry cough, and phlegm.
I would greatly appreciate any advice you could provide! Thank you!

Miss Wang, 50~59 year old female. Ask Date: 2022/07/08

Dr. Lin Minghui reply Gastroenterology and Hepatology

1.
The esophageal mucosal biopsy from the upper gastrointestinal endoscopy shows intestinal metaplasia, which raises the suspicion of Barrett's esophagus.
There is a certain degree of chronic inflammation present in the intestinal metaplasia.

2.
Treatment for Barrett's esophagus includes pharmacological therapy, lifestyle modifications, and surgical intervention.
Proton pump inhibitors (PPIs) should be used for gastroesophageal reflux disease (GERD) for 4 months according to health insurance regulations, while Barrett's esophagitis may require treatment for up to one year.

3.
For esophageal ulcers, follow-up is necessary to assess for improvement, and Barrett's esophagus should be monitored for any signs of dysplasia.
Endoscopic surveillance is required.
The timing for repeat endoscopy should be evaluated by the physician based on clinical conditions, which may be 4 months, 6 months, or up to one year, but not exceeding one year.

4.
For gastroesophageal reflux symptoms (heartburn, acid regurgitation) that have not improved after more than 8 weeks of medication, or for atypical GERD symptoms (unexplained cough, non-cardiac chest pain) that have not improved after more than 8 weeks of treatment, 24-hour esophageal impedance and pH monitoring, as well as esophageal manometry, can be performed before and after surgical evaluation for GERD.
Wishing you good health!

Reply Date: 2022/07/08

More Info

Barrett's esophagus is a condition that arises when the normal squamous cells lining the esophagus are replaced by columnar cells, a process known as intestinal metaplasia. This change is often a result of chronic gastroesophageal reflux disease (GERD), where stomach acid repeatedly irritates the esophagus. Your pathology report indicates the presence of intestinal metaplasia, which is a key feature in diagnosing Barrett's esophagus. The presence of ulcers at the esophagogastric junction and chronic inflammation further supports this diagnosis.

1. Diagnosis of Barrett's Esophagus
Based on your endoscopic findings and pathology report, it appears that Barrett's esophagus has indeed been identified. The report mentions "intestinal metaplasia," which is significant because it indicates that the cells have undergone a transformation that can predispose you to esophageal adenocarcinoma, a type of cancer. The severity of Barrett's esophagus can vary, and it is classified based on the length of the affected segment and the presence of dysplasia (abnormal cell growth). Since your report does not indicate dysplasia, it suggests that your condition may be in a less severe stage, but regular monitoring is essential.

2. Treatment and Management
You mentioned that you have been on proton pump inhibitors (PPIs) for over three months with only slight improvement in symptoms. PPIs are the mainstay of treatment for Barrett's esophagus and GERD, as they reduce stomach acid production, allowing the esophagus to heal. It is generally recommended to continue PPI therapy for at least six months to a year, especially in cases of Barrett's esophagus, to manage symptoms and prevent further damage. However, given your concern about osteoporosis and calcium absorption, it is crucial to discuss this with your healthcare provider. They may recommend monitoring your bone density and possibly supplementing calcium and vitamin D to mitigate the risk of osteoporosis exacerbated by long-term PPI use.

3. Follow-Up Endoscopy
Regular surveillance endoscopies are recommended for patients with Barrett's esophagus to monitor for dysplasia or cancer development. The frequency of these endoscopies can vary based on the findings. If no dysplasia is found, endoscopy is typically recommended every three to five years. However, if dysplasia is detected, more frequent surveillance or intervention may be necessary. Given your current diagnosis, it would be prudent to discuss with your physician when your next endoscopy should be scheduled.

4. 24-Hour pH Monitoring
Regarding the need for a 24-hour pH monitoring test, this is often performed if there is uncertainty about the diagnosis of GERD or if symptoms persist despite treatment. This test measures the acidity in the esophagus over a 24-hour period and can help confirm whether acid reflux is contributing to your symptoms. Given your ongoing symptoms of chest pressure, belching, and cough, this test might provide valuable information to guide further management.

Lifestyle Modifications
In addition to medication, lifestyle modifications play a crucial role in managing Barrett's esophagus and GERD. Here are some recommendations:
- Dietary Changes: Avoid foods that trigger reflux, such as spicy foods, citrus, chocolate, caffeine, and fatty foods. Eating smaller, more frequent meals can also help.

- Weight Management: Maintaining a healthy weight can reduce pressure on the stomach and lower the risk of reflux.

- Elevate the Head of the Bed: Sleeping with the head elevated can help prevent nighttime reflux.

- Avoid Lying Down After Meals: Wait at least three hours after eating before lying down to minimize reflux risk.

- Quit Smoking: If you smoke, quitting can significantly improve your symptoms and overall health.

In conclusion, Barrett's esophagus requires careful management and regular monitoring. Continue your PPI therapy, adhere to lifestyle modifications, and maintain regular follow-ups with your healthcare provider to monitor your condition. It’s essential to have open communication with your physician regarding your concerns and treatment options to ensure the best possible outcomes.

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