The Specialty certificate in Gastroenterology SCE covers the whole of the curriculum of the specialty training in gastroenterology in the UK. Preparation for this exam requires a wide breadth of knowledge around the curriculum . As knowledge is constantly advancing , awareness of current and updated guidelines is important.This blog is an attempt to pool all resources in one site with regular updates.
Dr Elmuhtady Said
Curriculum for Specialty Certificate Examination in Gastroenterology
Definition:
BO is defined as an oesophagus in which any portion of the normal distal squamous epithelial lining has been replaced by metaplastic columnar epithelium, which is clearly visible endoscopically (>1 cm) above GOJ and confirmed histopathologically from oesophageal biopsies. BSG 2013
The prevalence of Barrett's oesophagus is just under 2% among adults in the west. The life time risk is 5% in men and 3% in women.
Patients with Barrett's oesophagus have a yearly risk of developing oesophageal adenocarcinoma of between 0.3 and 0.5% depending on the segment length and presence of intestinal metaplasia.
The aim of surveillance is to detect patient at greater risk of progressing to OAC at early curative stage.
Major risk factors associated with progression to cancer are: male gender, whte ethnicity, length of Barrett's in cm, poor diet in veg and fruits and high fat, smokinf and obesity.
NICE adviced that patients with symptoms of reflux for more than 5-10 years should be referred for screening endoscopy to check for Barrett's oesophagus or its complications.
Patients with Barrett's oesophagus may be given one of the following results following histology:
No dysplasia - these patients should return to the usual surveillance programme
Low grade dysplasia - these patients should be offered a follow up endoscopy in six months' time
High grade dysplasia - these patients should be referred to the upper gastrointestinal MDT for further surgical management
Indefinite for dysplasia - these patients should be treated with a proton pump inhibitor, before having a repeat endoscopy in six months' time.
Non dysplastic Barrett's:
1- BO without IM < 3 cm discharge patient.
2- BO with IM < 3 cm, 3-5 years surveillance.
3- BO of 3 or more cm, 2-3 years surveillance
Management of Dysplastic Barrett's:
if low grade dysplasia is detected:
-Extensive biopsies after intensive acid suppression for 8-12 weeks, 6 monthly surviellance as long as the disease is stable.
-Based on current evidance, ablation therapy cannot be recommended routinely until data from RCT are available. -Clinicians may choose to treat some patients with low grade dysplasia with ablation, when the dysplasia is either persistent or multi focal.
-One disadvantage of ablation is that patients will need to continue with regular surveillance endoscopies
if high grade dysplasia detected:
-If changes persist after intensive acid suppresion and HGD is confirmed by 2 pathologists,
-After MDT discussion, refer to tertiary centre for expert HRE to detect visible lesions.
-Flat lesion: RFA
-Visible lesion: ER
-HGD/T1a cancer: RFA after resection
-T1b cancer: oesophagectomy in a specialised unit.
A 52-year-old Caucasian male with recently diagnosed Barrett’s esophagus without dysplasia arrives for consultation regarding the risk of malignancy. The Barrett’s segment length is 2 centimeters [see figure]. Biopsies do not reveal evidence of dysplasia. What would you counsel this patient regarding his risk of cancer?
A. The risk of cancer is 0.5% per year.
B. The risk of cancer is only 0.1% per year.
C. The patient should undergo ablation therapy because of the risk of cancer.
D. The patient should be investigated with endoscopic ultrasound to evaluate for metastatic cancer.
E. The patient should be placed on a 81 mg tablet of aspirin every day.
correct answer B,
The most recent information based on a population-based study in Denmark suggests that the incidence of esophageal carcinoma in non-dysplastic Barrett’s esophagus is only 1 per thousand patient-years. This is lower than the previous estimate of 0.5%. Ablation therapy has not been found to reduce cancer incidence in a prospective study. Endoscopic ultrasound is not useful in this situation. Although aspirin has been shown to decrease the risk of esophageal cancer, this has not yet been proven in a prospective study.
A 56-year-old Caucasian male is referred to you for a short segment of Barrett’s esophagus with high-grade dysplasia. Two expert pathologists have confirmed this diagnosis. The patient is asymptomatic on proton pump inhibitors. What would you do with this Barrett’s esophagus?
A. Take careful biopsies every centimeter in 4 quadrants with a jumbo forceps.
B. Carefully inspect the mucosal surface after applying Lugol's solution.
C. Perform an endoscopic ultrasound.
D. Perform an endoscopic mucosal resection.
E. Refer the patient to a surgeon for esophagectomy.
correct answer D
Explanation
The patient has a nodule in the Barrett’s esophagus segment. The standard of care for this patient would be to perform an endoscopic mucosal resection. Endoscopic ultrasound may not be necessary given the low yield in the setting of high-grade dysplasia. The endoscopic mucosal resection could be regarded as diagnostic as this may reveal adenocarcinoma as well as therapeutic. Surgical intervention may not be needed depending on the nature of the lesion.
An otherwise healthy 45-year-old male presents with a history of intermittent heartburn for 20 years. An upper endoscopy is performed which reveals a 5 cm segment of Barrett’s esophagus without dysplasia. You recommend a repeat upper endoscopy for surveillance in:
A 46-year-old male with a history of Barrett’s esophagus and low-grade dysplasia presents for routine surveillance endoscopy. Upper endoscopy demonstrates an island of Barrett's with nodularity. Biopsies are taken of this lesion, and they show Barrett’s esophagus with high-grade dysplasia. The next appropriate step in this patient’s management is:
A. Radiofrequency ablation with a circumferential RFA device
B. Repeat endoscopy with endoscopic surveillance in 3 months
C. Endoscopic mucosal resection with a band and ligation technique
D. Esophagectomy
correct answe C Explanation
Radiofrequency ablation for Barrett's with high-grade dysplasia is inappropriate, since tissue damage imposed by radiofrequency ablation may be too superficial to obliterate the lesion. Therefore, the lesion should be removed prior to ablative therapy. Given the presence of nodularity, this is considered a high-risk lesion, which makes repeat endoscopic surveillance a poor choice. Response rates with endoscopic mucosal resection followed by ablation are quite high so that esophagectomy can generally be avoided in Barrett’s esophagus patients with this condition.
A 65-year-old male undergoes radiofrequency ablation for long segment (C4M6) Barrett’s esophagus with high-grade dysplasia. Follow-up endoscopy confirms both endoscopic and histological absence of Barrett’s esophagus. Which of the following is an appropriate follow-up instruction?
A. Cessation of PPI and dietary measures to avoid GERD
B. Endoscopic ultrasound at yearly intervals to detect subsquamous Barrett’s esophagus
C. Periodic upper endoscopy to assess for recurrent Barrett’s esophagus
D. Daily aspirin
correct answer C Explanation
Recurrent Barrett’s esophagus develops in approximately 20% of subjects who have undergone radiofrequency ablation for dysplastic Barrett’s esophagus. This is usually amenable to further ablative therapy. Therefore, periodic upper endoscopy as a surveillance tool is suggested, although the optimal interval has not yet been determined. PPI cessation is not recommended, given that ablation does not inhibit reflux disease, and recurrent BE in the unprotected mucosa may occur. EUS is not effective at detecting subsquamous BE, and currently is not used in post-ablation monitoring. There are no data to support aspirin as an anti-neoplastic measure after endoscopic ablation.
A 42-year-old female with nondysplastic Barrett’s esophagus (BE), Prague classification C0M2, seeks your consultation regarding possible preventative measures to decrease the likelihood of progression of her Barrett’s esophagus to cancer. Which of the following options have demonstrated a protective effect against disease progression in BE in prospective trials?
An otherwise healthy 73-year-old male with a history of nondysplastic Barrett's esophagus presents for surveillance endoscopy. Endoscopy reveals long segment Barrett’s esophagus, Prague classification C4M6, with some nodularity 1 cm proximal to the GE junction. Endoscopic mucosal resection (EMR) of the lesion shows high-grade dysplasia, with a focus of adenocarcinoma, with a maximal depth of invasion to the mid-submucosa (sm2). The lateral margins of the EMR are clear of cancer. The next most appropriate step is:
A. Radiofrequency ablation of the remaining BE
B. Esophagectomy with possible chemoradiation
C. Repeat EMR to achieve a wider excision
D. Repeat EGD with biopsies in 3 months
correct answer B Explanation
This patient’s cancer has invaded beyond the superficial submucosa. Although the resected specimen appears clear of disease at its lateral margins, the status of the deep margin is often difficult to ascertain in EMR specimens, and the likelihood of lymphatic involvement in cancers that have penetrated beyond the superficial submucosa is substantial so esophagectomy with possible chemoradiation is the best treatment choice for this patient.
A 46-year-old man with a history of Barrett’s and low-grade dysplasia undergoes surveillance upper endoscopy. On that exam, the endoscopic picture in the figure is noted. Biopsies of the lesion demonstrate low-grade dysplasia. Appropriate management is:
A. Endoscopic mucosal resection of the lesion
B. Radiofrequency ablation of the Barrett’s segment
C. Surveillance endoscopy in 6 months
D. Esophagectomy
correct answer A Explanation
The endoscopist should take little comfort in the relatively benign nature of the histology obtained with cold biopsies, since sampling error may cause a more serious lesion to go unrecognized. Biopsies may understage lesions as the biopsy does not often obtain a large amount of submucosal tissue and the use of larger resection methods are warranted. Under-treatment of unrecognized more serious disease may lead to the development of metastatic cancer and the loss of opportunity for cure. For this reason, nodular dysplastic disease in BE should undergo EMR, both for accurate staging of the disease, and to remove the lesion. With lesions that are greater than 1.5 centimeters in diameters, there have been suggestions to perform endoscopic submucosal resection to completely remove a neoplastic lesion.
A 56-year-old woman with a history of Barrett’s esophagus for 8 years undergoes routine surveillance endoscopy. Two centimeters of non-nodular, circumferential Barrett’s is noted on endoscopic exam 34-36 cm from the incisors, with a 3 cm hiatal hernia beneath. The pathology report notes unifocal low-grade dysplasia (one out of 8 biopsies positive). The next most appropriate step is:
A. Repeat the examination to obtain more tissue
B. Have the current tissue re-read by a pathologist expert in gastrointestinal pathology
C. Radiofrequency ablation of the involved tissue
D. Nissen fundoplication with repair of the hiatal hernia
correct answer B Explanation
The reproducibility of a diagnosis of low grade dysplasia is poor. It also is associated with a variable clinical course with apparent regression on endoscopic biopsy to non-dysplastic mucosa being fairly common. Most studies demonstrate at best relatively modest agreement between pathologists for this diagnosis. Therefore, before contemplating changing the therapeutic approach to the patient, the diagnosis should be confirmed by a second pathologist with expertise in gastrointestinal pathology.
Which of the following statements regarding Barrett's esophagus is correct?
A. Clonal molecular abnormalities are absent until there is morphologic expression of dysplasia.
B. Patients with goblet cells are at risk for malignancy.
C. Patients with low-grade dysplasia cannot be managed by increased endoscopic surveillance; all should undergo endoscopic ablation.
D. Patients with high-grade dysplasia are managed best by endoscopic ablation and endoscopic mucosal resection, increased surveillance, or esophagectomy.
correct answer B Explanation
Although there have been recent retrospective studies that have shown that patients with esophageal columnar metaplasia, but without goblet cells, may also progress to dysplasia and cancer, it appears that cancers are much more likely in patients with goblet cells. During progressive neoplasia, goblet cells are lost since they represent a more differentiated type of mucosa. Clonal molecular abnormalities can occur independently of dysplasia as can a number of molecular events. Low grade dysplasia has a relatively low risk of progression to cancer but certain patients may be at higher risk (those with molecular abnormalities). Ablation in these patients can be considered but most can be managed with surveillance. Patients with high grade dysplasia are generally recommended for therapy depending on their condition. Esophagectomy is an option for non-compliant patients and surveillance may be done in patients who have more limited survival and who may not tolerate ablative therapy.
A 42-year-old woman with non-dysplastic Barrett’s esophagus, Prague classification C0M2, seeks your consultation regarding possible preventive measures to decrease the likelihood of progression of her disease to cancer. Which of the following have prospective data demonstrating a protective effect against disease progression in BE?
A. NSAID use
B. Proton pump inhibitor therapy
C. Weight loss
D. None of the above
correct answer D Explanation
While several chemopreventive measures have been championed for patients with BE, the data supporting the measures is weak or absent. Retrospective trials of PPIs demonstrate that subjects with BE who are treated are less likely to progress to dysplasia. Epidemiological studies show that subjects on NSAIDs appear less likely to progress to esophageal cancer. However, prospective data on all the measures above are lacking. While most subjects with diagnosed BE have GERD symptoms which require acid suppressive therapy, high doses of the medications are of unclear benefit in terms of preventing malignancy.
An otherwise healthy 73-year-old man with a history of non-dysplastic BE presents for surveillance endoscopy. Endoscopy reveals long segment Barrett’s esophagus, Prague classification C4M6, with some nodularity 1 cm proximal to the GE junction. Endoscopic mucosal resection (EMR) of the lesion shows high-grade dysplasia, with a focus of adenocarcinoma, with a maximal depth of invasion to the mid-submucosa (sm2). The lateral margins of the EMR are clear of cancer. The next most appropriate step is:
A. Radiofrequency ablation of the remaining BE
B. Esophagectomy with possible chemoradiation
C. Repeat EMR to achieve a wider excision
D. Repeat EGD with biopsies in 3 months
correct answer B Explanation
This patient’s cancer has invaded beyond the superficial submucosa. Although the resected specimen appears clear of disease at its lateral margins, the status at the deep margin is often difficult to ascertain in deep lesions, and the likelihood of lymphatic involvement in lesions that have penetrated beyond the superficial submucosa is substantial, and argues for more aggressive multimodality therapy.
The British Society of Gastroenterology guidelines advise that you should consider referring patients for a screening endoscopy if they have chronic symptoms of gastro-oesophageal reflux together with three or more of the following risk factors for Barrett's oesophagus :
Male sex Age over 50 Abdominal obesity White race. This guidance from the British Society of Gastroenterology (BSG) is also in line with the current American Gastroenterology Association guidelines.
You should have a lower threshold for referral if a patient has a first degree relative with either Barrett's oesophagus or oesophageal adenocarcinoma. Both of these risk factors put patients at higher risk of developing Barrett's oesophagus.
HOW OFTEN SHOULD PATIENTS BE OFFERED A SURVEILLANCE ENDOSCOPY? This depends on the length of Barrett's oesophagus, as well as the subtype of Barrett's oesophagus that is seen on histology.
Management recommendations include :
1- Discharge from surveillance. This is a reasonable option if the length of Barrett's oesophagus is less than 3 cm, and no intestinal metaplasia is found on two occasions
2- Surveillance every three to five years. This is recommended when the length of Barrett's oesophagus is less than 3 cm, but intestinal metaplasia is found.
3- Surveillance every two to three years. This is recommended when the length of Barrett's oesophagus is greater than 3 cm.
This advice does not apply to patients with biopsies showing evidence of dysplasia, who are considered as a separate group.
Interesting topic for a blog. I have been searching the Internet for fun and came upon your website. Fabulous post. Thanks a ton for sharing your knowledge! It is great to see that some people still put in an effort into managing their websites. I'll be sure to check back again real soon. natural way of birth control
I was diagnosed as HEPATITIS B carrier in 2013 with fibrosis of the liver already present. I started on antiviral medications which reduced the viral load initially. After a couple of years the virus became resistant. I started on HEPATITIS B Herbal treatment from ULTIMATE LIFE CLINIC (www.ultimatelifeclinic.com) in March, 2020. Their treatment totally reversed the virus. I did another blood test after the 6 months long treatment and tested negative to the virus. Amazing treatment! This treatment is a breakthrough for all HBV carriers.
A 52-year-old Caucasian male with recently diagnosed Barrett’s esophagus without dysplasia arrives for consultation regarding the risk of malignancy. The Barrett’s segment length is 2 centimeters [see figure]. Biopsies do not reveal evidence of dysplasia. What would you counsel this patient regarding his risk of cancer?
ReplyDeleteA. The risk of cancer is 0.5% per year.
B. The risk of cancer is only 0.1% per year.
C. The patient should undergo ablation therapy because of the risk of cancer.
D. The patient should be investigated with endoscopic ultrasound to evaluate for metastatic cancer.
E. The patient should be placed on a 81 mg tablet of aspirin every day.
correct answer B,
The most recent information based on a population-based study in Denmark suggests that the incidence of esophageal carcinoma in non-dysplastic Barrett’s esophagus is only 1 per thousand patient-years. This is lower than the previous estimate of 0.5%. Ablation therapy has not been found to reduce cancer incidence in a prospective study. Endoscopic ultrasound is not useful in this situation. Although aspirin has been shown to decrease the risk of esophageal cancer, this has not yet been proven in a prospective study.
A 56-year-old Caucasian male is referred to you for a short segment of Barrett’s esophagus with high-grade dysplasia. Two expert pathologists have confirmed this diagnosis. The patient is asymptomatic on proton pump inhibitors.
ReplyDeleteWhat would you do with this Barrett’s esophagus?
A. Take careful biopsies every centimeter in 4 quadrants with a jumbo forceps.
B. Carefully inspect the mucosal surface after applying Lugol's solution.
C. Perform an endoscopic ultrasound.
D. Perform an endoscopic mucosal resection.
E. Refer the patient to a surgeon for esophagectomy.
correct answer D
Explanation
The patient has a nodule in the Barrett’s esophagus segment. The standard of care for this patient would be to perform an endoscopic mucosal resection. Endoscopic ultrasound may not be necessary given the low yield in the setting of high-grade dysplasia. The endoscopic mucosal resection could be regarded as diagnostic as this may reveal adenocarcinoma as well as therapeutic. Surgical intervention may not be needed depending on the nature of the lesion.
An otherwise healthy 45-year-old male presents with a history of intermittent heartburn for 20 years. An upper endoscopy is performed which reveals a 5 cm segment of Barrett’s esophagus without dysplasia. You recommend a repeat upper endoscopy for surveillance in:
ReplyDeleteA. 6 months
B. 1 year
C. 2 years
D. 3 years
A 46-year-old male with a history of Barrett’s esophagus and low-grade dysplasia presents for routine surveillance endoscopy. Upper endoscopy demonstrates an island of Barrett's with nodularity. Biopsies are taken of this lesion, and they show Barrett’s esophagus with high-grade dysplasia. The next appropriate step in this patient’s management is:
ReplyDeleteA. Radiofrequency ablation with a circumferential RFA device
B. Repeat endoscopy with endoscopic surveillance in 3 months
C. Endoscopic mucosal resection with a band and ligation technique
D. Esophagectomy
correct answe C
Explanation
Radiofrequency ablation for Barrett's with high-grade dysplasia is inappropriate, since tissue damage imposed by radiofrequency ablation may be too superficial to obliterate the lesion. Therefore, the lesion should be removed prior to ablative therapy. Given the presence of nodularity, this is considered a high-risk lesion, which makes repeat endoscopic surveillance a poor choice. Response rates with endoscopic mucosal resection followed by ablation are quite high so that esophagectomy can generally be avoided in Barrett’s esophagus patients with this condition.
A 65-year-old male undergoes radiofrequency ablation for long segment (C4M6) Barrett’s esophagus with high-grade dysplasia. Follow-up endoscopy confirms both endoscopic and histological absence of Barrett’s esophagus. Which of the following is an appropriate follow-up instruction?
ReplyDeleteA. Cessation of PPI and dietary measures to avoid GERD
B. Endoscopic ultrasound at yearly intervals to detect subsquamous Barrett’s esophagus
C. Periodic upper endoscopy to assess for recurrent Barrett’s esophagus
D. Daily aspirin
correct answer C
Explanation
Recurrent Barrett’s esophagus develops in approximately 20% of subjects who have undergone radiofrequency ablation for dysplastic Barrett’s esophagus. This is usually amenable to further ablative therapy. Therefore, periodic upper endoscopy as a surveillance tool is suggested, although the optimal interval has not yet been determined. PPI cessation is not recommended, given that ablation does not inhibit reflux disease, and recurrent BE in the unprotected mucosa may occur. EUS is not effective at detecting subsquamous BE, and currently is not used in post-ablation monitoring. There are no data to support aspirin as an anti-neoplastic measure after endoscopic ablation.
A 42-year-old female with nondysplastic Barrett’s esophagus (BE), Prague classification C0M2, seeks your consultation regarding possible preventative measures to decrease the likelihood of progression of her Barrett’s esophagus to cancer. Which of the following options have demonstrated a protective effect against disease progression in BE in prospective trials?
ReplyDeleteA. NSAID use
B. Proton pump inhibitor therapy
C. Weight loss
D. None of the above
An otherwise healthy 73-year-old male with a history of nondysplastic Barrett's esophagus presents for surveillance endoscopy. Endoscopy reveals long segment Barrett’s esophagus, Prague classification C4M6, with some nodularity 1 cm proximal to the GE junction. Endoscopic mucosal resection (EMR) of the lesion shows high-grade dysplasia, with a focus of adenocarcinoma, with a maximal depth of invasion to the mid-submucosa (sm2). The lateral margins of the EMR are clear of cancer. The next most appropriate step is:
ReplyDeleteA. Radiofrequency ablation of the remaining BE
B. Esophagectomy with possible chemoradiation
C. Repeat EMR to achieve a wider excision
D. Repeat EGD with biopsies in 3 months
correct answer B
Explanation
This patient’s cancer has invaded beyond the superficial submucosa. Although the resected specimen appears clear of disease at its lateral margins, the status of the deep margin is often difficult to ascertain in EMR specimens, and the likelihood of lymphatic involvement in cancers that have penetrated beyond the superficial submucosa is substantial so esophagectomy with possible chemoradiation is the best treatment choice for this patient.
A 46-year-old man with a history of Barrett’s and low-grade dysplasia undergoes surveillance upper endoscopy. On that exam, the endoscopic picture in the figure is noted. Biopsies of the lesion demonstrate low-grade dysplasia. Appropriate management is:
ReplyDeleteA. Endoscopic mucosal resection of the lesion
B. Radiofrequency ablation of the Barrett’s segment
C. Surveillance endoscopy in 6 months
D. Esophagectomy
correct answer A
Explanation
The endoscopist should take little comfort in the relatively benign nature of the histology obtained with cold biopsies, since sampling error may cause a more serious lesion to go unrecognized. Biopsies may understage lesions as the biopsy does not often obtain a large amount of submucosal tissue and the use of larger resection methods are warranted. Under-treatment of unrecognized more serious disease may lead to the development of metastatic cancer and the loss of opportunity for cure. For this reason, nodular dysplastic disease in BE should undergo EMR, both for accurate staging of the disease, and to remove the lesion. With lesions that are greater than 1.5 centimeters in diameters, there have been suggestions to perform endoscopic submucosal resection to completely remove a neoplastic lesion.
A 56-year-old woman with a history of Barrett’s esophagus for 8 years undergoes routine surveillance endoscopy. Two centimeters of non-nodular, circumferential Barrett’s is noted on endoscopic exam 34-36 cm from the incisors, with a 3 cm hiatal hernia beneath. The pathology report notes unifocal low-grade dysplasia (one out of 8 biopsies positive). The next most appropriate step is:
ReplyDeleteA. Repeat the examination to obtain more tissue
B. Have the current tissue re-read by a pathologist expert in gastrointestinal pathology
C. Radiofrequency ablation of the involved tissue
D. Nissen fundoplication with repair of the hiatal hernia
correct answer B
Explanation
The reproducibility of a diagnosis of low grade dysplasia is poor. It also is associated with a variable clinical course with apparent regression on endoscopic biopsy to non-dysplastic mucosa being fairly common. Most studies demonstrate at best relatively modest agreement between pathologists for this diagnosis. Therefore, before contemplating changing the therapeutic approach to the patient, the diagnosis should be confirmed by a second pathologist with expertise in gastrointestinal pathology.
Which of the following statements regarding Barrett's esophagus is correct?
ReplyDeleteA. Clonal molecular abnormalities are absent until there is morphologic expression of dysplasia.
B. Patients with goblet cells are at risk for malignancy.
C. Patients with low-grade dysplasia cannot be managed by increased endoscopic surveillance; all should undergo endoscopic ablation.
D. Patients with high-grade dysplasia are managed best by endoscopic ablation and endoscopic mucosal resection, increased surveillance, or esophagectomy.
correct answer B
Explanation
Although there have been recent retrospective studies that have shown that patients with esophageal columnar metaplasia, but without goblet cells, may also progress to dysplasia and cancer, it appears that cancers are much more likely in patients with goblet cells. During progressive neoplasia, goblet cells are lost since they represent a more differentiated type of mucosa. Clonal molecular abnormalities can occur independently of dysplasia as can a number of molecular events. Low grade dysplasia has a relatively low risk of progression to cancer but certain patients may be at higher risk (those with molecular abnormalities). Ablation in these patients can be considered but most can be managed with surveillance. Patients with high grade dysplasia are generally recommended for therapy depending on their condition. Esophagectomy is an option for non-compliant patients and surveillance may be done in patients who have more limited survival and who may not tolerate ablative therapy.
A 42-year-old woman with non-dysplastic Barrett’s esophagus, Prague classification C0M2, seeks your consultation regarding possible preventive measures to decrease the likelihood of progression of her disease to cancer. Which of the following have prospective data demonstrating a protective effect against disease progression in BE?
ReplyDeleteA. NSAID use
B. Proton pump inhibitor therapy
C. Weight loss
D. None of the above
correct answer D
Explanation
While several chemopreventive measures have been championed for patients with BE, the data supporting the measures is weak or absent. Retrospective trials of PPIs demonstrate that subjects with BE who are treated are less likely to progress to dysplasia. Epidemiological studies show that subjects on NSAIDs appear less likely to progress to esophageal cancer. However, prospective data on all the measures above are lacking. While most subjects with diagnosed BE have GERD symptoms which require acid suppressive therapy, high doses of the medications are of unclear benefit in terms of preventing malignancy.
An otherwise healthy 73-year-old man with a history of non-dysplastic BE presents for surveillance endoscopy. Endoscopy reveals long segment Barrett’s esophagus, Prague classification C4M6, with some nodularity 1 cm proximal to the GE junction. Endoscopic mucosal resection (EMR) of the lesion shows high-grade dysplasia, with a focus of adenocarcinoma, with a maximal depth of invasion to the mid-submucosa (sm2). The lateral margins of the EMR are clear of cancer. The next most appropriate step is:
ReplyDeleteA. Radiofrequency ablation of the remaining BE
B. Esophagectomy with possible chemoradiation
C. Repeat EMR to achieve a wider excision
D. Repeat EGD with biopsies in 3 months
correct answer B
Explanation
This patient’s cancer has invaded beyond the superficial submucosa. Although the resected specimen appears clear of disease at its lateral margins, the status at the deep margin is often difficult to ascertain in deep lesions, and the likelihood of lymphatic involvement in lesions that have penetrated beyond the superficial submucosa is substantial, and argues for more aggressive multimodality therapy.
The British Society of Gastroenterology guidelines advise that you should consider referring patients for a screening endoscopy if they have chronic symptoms of gastro-oesophageal reflux together with three or more of the following risk factors for Barrett's oesophagus :
ReplyDeleteMale sex
Age over 50
Abdominal obesity
White race.
This guidance from the British Society of Gastroenterology (BSG) is also in line with the current American Gastroenterology Association guidelines.
You should have a lower threshold for referral if a patient has a first degree relative with either Barrett's oesophagus or oesophageal adenocarcinoma. Both of these risk factors put patients at higher risk of developing Barrett's oesophagus.
HOW OFTEN SHOULD PATIENTS BE OFFERED A SURVEILLANCE ENDOSCOPY?
ReplyDeleteThis depends on the length of Barrett's oesophagus, as well as the subtype of Barrett's oesophagus that is seen on histology.
Management recommendations include :
1- Discharge from surveillance. This is a reasonable option if the length of Barrett's oesophagus is less than 3 cm, and no intestinal metaplasia is found on two occasions
2- Surveillance every three to five years. This is recommended when the length of Barrett's oesophagus is less than 3 cm, but intestinal metaplasia is found.
3- Surveillance every two to three years. This is recommended when the length of Barrett's oesophagus is greater than 3 cm.
This advice does not apply to patients with biopsies showing evidence of dysplasia, who are considered as a separate group.
Interesting topic for a blog. I have been searching the Internet for fun and came upon your website. Fabulous post. Thanks a ton for sharing your knowledge! It is great to see that some people still put in an effort into managing their websites. I'll be sure to check back again real soon. natural way of birth control
ReplyDeleteI think so. I think your article will give those people a good reminding. And they will express thanks to you later suffolk county department of health services office of wastewater management
ReplyDelete
ReplyDeleteGet consultation for liver diseases and disorders from Dr. Sandeep Kumar Jha
liver specialist doctor in delhi
I was diagnosed as HEPATITIS B carrier in 2013 with fibrosis of the
ReplyDeleteliver already present. I started on antiviral medications which
reduced the viral load initially. After a couple of years the virus
became resistant. I started on HEPATITIS B Herbal treatment from
ULTIMATE LIFE CLINIC (www.ultimatelifeclinic.com) in March, 2020. Their
treatment totally reversed the virus. I did another blood test after
the 6 months long treatment and tested negative to the virus. Amazing
treatment! This treatment is a breakthrough for all HBV carriers.