During this 20-25 minute pre-recorded lecture, Dr. Satish Nagula discusses the topic of Barrett's esophagus. This in-depth review will provide an update on this topic for your clinical practice as well as supplement your learning for the ABIM Gastroenterology and Hepatology boards.
CME pre-requiste of live Q & A webinar, 8th Annual Mount Sinai Intensive Board Review in Gastroenterology & Hepatology on Sept 22 Thank you for joining us today in this online version of our intensive border view in gastroenterology and hepatology. Today we'll be talking to you about their esophagus. This would be a case based presentation. And so we'll go through some of the major components of barrett's esophagus. Uh through the discussion of multiple different cases. Case number one, A 45 year old male undergoes colonoscopy and upper endoscopy for the evaluation of the positive stools. Colonoscopy is unremarkable except for internal hemorrhoids which of the following. An upper endoscopy is consistent with barrett's esophagus. So the definition of barrett's esophagus as you must have at least one centimeter of metal plastic columnar epithelium that replaces the normal stratified squamous epithelium in the distal esophagus with histological evidence of intestinal metropole asia. The g junctions often regular. So tongues of less than one centimeter are absolutely normal intestinal made a pledge of the g junction actually represents intestinal, made a pledge of the card and the stomach and thus it's not there. It's there is actually no evidence of malignant progression of I am of the cardia in multiple longitudinal studies. So if we look at the pictures that I had posted up earlier. Look at this first image here. Now, what we're looking for is tongues that are at least one centimeter long. So the g junctions way in the distance, we have a long tongue or long area of salmon colored mucosa. So as long as biopsies here confirm the testing by the pleasure that is barrett's esophagus. Here's another image of a different patient and you can actually see the rugal folds coming right up to the screen, more culinary junction. So again it's rugal folds coming right up. And so this here is actually a normal ge junction. You should not biopsy this junction here because you're going to get biopsies of the gastric cardia. So this will not be barrett's esophagus. Regardless of your histological findings. Over here, again, you can see the gastric folds coming up to the screen or columbus junction. And again, you see it over here as well. So although this is a little bit jagged, this is actually not bear its. Many people look at this jagged scream or culinary junction and say, oh that's an irregular Z line. If the biopsy show a testament of pleasure, that must be bear it. So that would be incorrect because again, you have to have a one centimeter tongue at minimum to be considered barrett's esophagus. And on this last diagram here, the G junctions who down here in the distance and you get this uh this area of salmon colored mucosa. And assuming again, biopsies show and testament APL asia, they should be certainly consistent with barrett's esophagus. So again, in this diagram of barrett's esophagus, you can or of the histology of barrett's esophagus, you can see here, normal stratified squamous epithelium. And then once you have barrett's esophagus, this stratified squamous epithelium is now changed to Colombia epithelium. Um and these little goblet cells or what gives it that what we call specialized intestinal meta play asia. So the key here is whether or not they are the presence of God itself. Now one of the standard ways we use to document barrett's esophagus is to use the Prague CNN classification and the reason to use this is a sort of establishes a standard way of communicating and describing barrett's esophagus. I like to think of barrett's esophagus as a disease related to surface area. So somebody who's got 15 centimetre tongue of barrettes, It's going to likely have a very different risk profile than someone who's got five cm of circumferential barrettes. So what you do here is starting at the G junction. Uh you first document how long the circumstantial barrettes is. So this would be two centimeters of circumstantial barrettes at C. Two. And the end is the maximum length. So again starting at the G junction all the way up to the tip of the tallest tongue. So this is C. Two M. Five. That right there gives you a mental image of something that actually has far less surface area and somebody who is C. Five M. Five or five centimeters of circumferential disease. So let's think about who is at risk for barrett's esophagus. So if we think about some of our major um risk factors we look at a show patients who are older and much more likely to have barrett's esophagus when we look at ethnicity. So patients who are african american are far less likely, 70 65% 70% less likely to have barrett's compared to caucasians. And the same is true for asians and Hispanics, caucasians are by far and away, much more likely to get. Barrett's esophagus patients who are obese also have uh 1.5 to 2 fold increase in the risk of development. Barrett's esophagus smoking is also an important consideration as well, Although we classically associate um smoking and drinking with a squamous cell carcinoma pathway, smoking actually certainly increases the risk of barrett's esophagus by 1.5 to 2 folds. Family history is by far and away, the biggest risk factor. So, a family history of barrett's esophagus cancer or ge junction cancer is a tall fold increased risk of barrett's esophagus. So all in all this led to the 2016 ACG guidelines which actually advocated for screening for Paris, but they are looking for screening for barrettes and men with chronic symptoms. So, greater than five years. Um and also who have two or more risk factors for barrett or esophageal cancer. So that includes age over 50 caucasian race. Central obesity, current or past history of smoking and I confirmed family history of bears or esophageal adenocarcinoma. So if you can imagine a overweight male, white male who is over 50 years old with chronic reflux. That's a lot of patients and all of these patients should be considered for at least a one time upper endoscopy to screen for barrett's esophagus case number two. This is a 62 year old attorney with a seven year history of chronic er It comes in for an upper endoscopy who reports no symptoms on Penta parasol 40 mg every morning you perform an upper endoscopy and there's a three centimeter segment affairs esophagus product classification C two M three pathology reveals non dis plastic barrett's esophagus. According to the 2016 80 G guidelines, what is the best surveillance strategy, repeat E G. D. In one year, repeat E G. D. In 3 to 5 years, repeat E. G. In six months or repeat E. G at age 50. The answer here is repeating the G. D. in 3 to 5 years. So this is a change from uh the guidelines prior to 2016. Um older guidelines advocated for a confirmatory endoscopy in one year. But starting in 2016 the current guidance is that if adequate biopsies were taken during the index endoscopy then there is no role for confirmatory endoscopy within a year. So now the surveillance intervals Fernandez plastic Barrett's esophagus is 3-5 years. There's certainly a tendency to over scope their patients with barrett's esophagus. The general understanding here is the risk of non dis plastic barrett's esophagus progressing is relatively low and so the surveillance intervals will really be 3 to 5 years personally. I tailor this based on age and comorbidities. So patients with multiple comorbidities are very advanced age. I tend more towards five years if at all patients who are younger and healthier. I tend towards more three years. Um uh One area of great controversy is the management of a definite for dysplasia. So inflammation can really confound the pathologic grading particularly with regards to a diagnosis of low grade dysplasia. The histological diagnosis of low grade dysplasia is actually quite challenging requires certainly expert opinion. Yeah. Okay. The trick here is indefinite for dysplasia is not an in between point between non dis plastic barrettes and low grade dysplasia. Indefinite for dysplasia is where you just can't really identify as this sort of normal. Or is this low grade dysplasia? So the inflammatory changes from reflux can actually cause some uh some disturbance in the structure of the cells. And so it can be difficult to identify exactly what the histology is. The high dose P. P. I. So high dose twice daily PP. I can actually reduce the inflammation. Um and then you can often repeat the biopsy uh in 3-6 months and this allows you uh a clearer picture of what's really there. Okay. Um Short term follow up is certainly recommended. Some studies do suggest a higher risk of progression to low grade dysplasia within the first year. Um So it is important to really um make sure you have a definitive understanding of what the histology is repeat that procedure in three months and then you can see oh it's really low great. Now you can manage accordingly. Or you might find that it's actually truly non dis plastic case number 3 52 year old man with a new diagnosis of barrett's esophagus with low grade dysplasia comes to you for a second opinion. Priority. Oscar peas. Over the past 10 years have shown intestine meta pleasure without dysplasia. He has a five centimeter segment of barrett's esophagus without any natural allegiance. This gross symptoms that have long been well controlled on a twice daily p P I E G. Three months ago this local hospital shows focal area and focal areas of low grade dysplasia. According to the 2016 guidelines. Which are the following is a recommended management strategy, repeat endoscopy with biopsy is in three months, perform radio frequency ablation, obtain expert review of pathology slides or add an H two receptor antagonists at bedtime. Okay, the answer here is obtained an expert review of pathology slides, as mentioned in the previous slide, there is really significant inter observer variability in the diagnosis of low grade dysplasia. You need to have an expert gi pathologies review this. In some recent randomized trials, 85% of patients with low grade dysplasia were actually downgraded to non dis plastic barrett's esophagus After expert review radio frequency ablation is now the preferred strategy for the management of low grade dysplasia. Of course this assumes you have already, you've already obtain that expert review. So those that are truly low grade dysplasia are now well identified and those patients have a higher risk of progression. So after the initial diagnosis of low grade dysplasia the guidelines recommending optimized anti Secretary therapy to decrease inflammatory changes and then perform a repeat endoscopy with biopsy. I'll see clinically. It all sort of depends on the patient. If a patient has a long segment of barrett's esophagus when a long history of barrettes I tend to believe the fact that it is a true low grade dysplasia. But every so often I have patients with the new diagnosis of one centimeter of barrett's esophagus. And those patients I think there is room to optimize the anti secretary therapy Before committing the patient to treatment. It's critical again to review the Seattle protocol. Um Four quadrant because there were two centimeters for non dis plastic barrettes and then four quadrant biopsies every one centimeter for just plastic E. Yeah Chase for The 58 year old man has an e.g. for the evaluation of chronic regurgitation and heartburn. He is noted to have a six centimeter segment. Barrett's esophagus broad classification C. Four M. Six but they millimeters nodule at the G junction biopsy revealed high grade dysplasia of the nodule and non despotic barrett's esophagus through the rest of the segment which management option is the most appropriate next step a referral for a Selfridge ectomy be referred for chemo radiation he referred for C. T. Your pet D perform radio frequency ablation E. Perform endoscopic mucosal resection of the nodule? The answer here is perform and then discovering mucosal resection of the nodule. Now what managed an option would you choose if I if she's a nodule revealed interview coastal adenocarcinoma Instead same options as a project to me. Chemo radiation, ct pet radio frequency ablation or an EMR of the nodule. Then the answer here is an EMR of the it's important to understand um the significance of these knowledge tools and why we do um endoscopic mucosal resection. So in early esophageal adenocarcinoma. If the if the tumor itself is just confined to the mucosa. Um the risk of leftover tests it's only 125%. So patients with low risk of lymph node metastases can actually be cured with the M. R. Now what if the lesion was deeper and goes into the subject cosa now once the lesion is deep in the subject, most of the risk of lymphoma taxes this is 1-25%. So those are the high risk of leftover test as this requires surgical resection. The reason here is when they do a surgical resection they not only remove the primary tumor but actually remove the entire look no chain and that prevents um later uh recurrence. Whereas in the patients with only mucosal invasion. And that low risk of metastasis will the mortality or the complications of the surgery is actually on par if not higher than the risk of metastases and that's why I am. Are safe for that mucosal disease. That mucosal disease requires a surgical reception. So uh here's a flow diagram from those recent from this guideline to 2016 in patients with visible modularity and barrett's esophagus, we recommend E. M. R. If there's low grade dysplasia in that natural then the patient moves on to ablation. Uh Again with that naturally go to EMR and if it's high grade dysplasia we go on to ablation for the rest of the barretts In patients the T. one a. So that mucosal esophageal adenocarcinoma. If there's favorable histology such as as well differentiated, then you can move on to a bleeding the rest of the barretts. If it's a. T. One V. Tumor, that means into the 70 cosa. Well these are patients you need to discuss that a multidisciplinary oncology group is the patient in Canada for surgery. Or would you maybe go for chemo radiation. Um This is something that it really is best discussed with surgical colleagues as well as your oncology colleagues. Case number 5 47 year old male with longstanding GERD and barrett's esophagus recently diagnosed with high grade dysplasia. He undergoes two sessions of R. F. A. With complete remission from intestinal meta play asia what we would call crim cr. I. Am. What is the next step in management for the surveillance. Unless you symptoms develop repeat E. G. D. In three months continue high dose P. P. I. E. G. D. In one year or the U. S. Exam in six months. The answer here is repeating the G. D. in three months. The recurrence of intestinal dysplasia after successful ablation is about 20% with 2-3 years. Because of the surveillance should be performed every three months for one year after crim there will be six months for a year and then annually and then patients who develop recurrent and testament of pleasure or dysplasia. Those patients are readily treated with repeat ablation and or EMR in this last slide here I just wanted to review the risk of malignancy from the different stages of barrett's esophagus as well as just go over the efficacy of radio frequency ablation. So impatient with no dysplasia, the risk of progression to malignancy is about .22.5%. And low grade dysplasia In um in patients with confirmed low grade dysplasia from an expert pathologist. That risk is now understood to be a 10% annual risk of progression to esophageal adenocarcinoma And patience is high grade dysplasia. There's a 20% annual risk of progression to malignancy. And then if we look at the data regarding the efficacy of radio frequency ablation. A large meta analysis with with about 3800 patients shows that there is a 70% remission of Intesa meta play asia And a 91% permission of Dysplasia. This all this speaks to the incredible efficacy of endoscopic therapy for barrett's esophagus uh as as well as for high grade dysplasia and even early cervical adenocarcinoma. But as mentioned, there is indeed a recurrence rate of 15-20%. And so it is important to continue to survey those patients because there is such a high efficacy for re treatment in those patients. Thank you all for joining me with our in my talk today. Uh Please refer you to email me directly with any questions, um or join us during our live Q and A sessions in the coming weeks.