What is TRUE regarding Barrett’s esophagus –
Correct Answer: Premalignant condition
Description: About option (a)
Barrett's esophagus is more common in men than in women (3 : 1 ratio)
About option (c)
Schwartz surgery and CSDT writes that Barrett's esophagus can be reversed but only with antireflux surgery (response to medications is not good). Read below lines from CSDT (13/e p438) Schwartz (9/e p841): CSDT writes-"A fundoplication may promote regression of the columnar epithelium. Many studies have shown that regression occurs in 15-50% of patients when the length of the Barrett segment is less than 3 cm."
Schwartz writes- "The common belief that Barrett's epithelium cannot be reversed is likely false. DeMeester and associates reported that, after antireflux surgery, loss of IM (intestinal metaplasia) in patients with visible BE was rare, but occurred in73% of patients with inapparent IM of the cardia. This suggests that the metaplastic process may indeed be reversible if reflux is eliminated early in its process, that cardiac mucosa is dynamic, and that, as opposed to IM extending several centimeters into the esophagus, IM of the cardia is more likely to regress following antireflux surgery.
Gurski and colleagues reviewed pre- and posttreatment endoscopic biopsies from 77 Barrett's patients treated surgically and 14 treated with PPIs. Histopathologic regression occurred in 28 of 77 patients (36.4%) following antireflux surgery, and in one of 14 (7.1%) patients treated with PPlsalone (P <.03). After surgery, regression from low-grade dysplastic to nondysplastic BE occurred in 17 of 25 (68%) patients and from IM to no IM in 11 of 52 (21.2%) patients. Both types of regression were significantly more common in short- (<3 cm) compared to long-segment (>3 cm) BE.
Although these studies do not conclusively prove the ability of antireflux surgery to reverse the changes of early BE, they do provide encouragement that, given early changes, the process may indeed be reversible."
More about the tit of Barret's oesophagus
First, the natural course of Barrett's oesophagus.
- Barrett's esophagus develops during healing of erosive esophagitis with continued acid reflux and the Barrett's esophagus progresses through a dysplastic stage before developing into adenocarcinoma. The stages are
- Erosive esophagitis → Metaplasia (Barrett's esophagus) → Low grade dysplasia → high grade dysplaisa → Adenocarcinoma
Treatment of Barrett's esophagus is same as for reflux esophagitis → Conservative (antacids, H2 blocking agents, elevation of the head of bed, and avoidance of smoking and alcohol etc.) and Anti-reflux surgery (Nissen's fundoplication is anti-reflux procedure of choice)
As there is substantial increased risk of cancer with Barrett's esophagus, a regular follow-up with endoscopy and biopsy is done. This allows detection of cancer at an early stage with improved long-term survival after resection
In the absence of dysplasia → Surveillance endoscopy every 12-24 months.
In the presence of low-grade dysplasia →
Patients with low grade dysplasia should be treated for 12 weeks with high-dose acid suppression therapy and then biopsy repeated. (the rationale for this approach is to decrease the mucosal inflammation by blocking acid secretion, allowing the pathologist a more accurate reading),If the repeated biopsy show metaplasia or high-grade dysplasia, the patient should be managed accordingly. If repeated low-grade dysplasia is seen- surveillance endoscopy is done every 6-12 months.
If high grade dysplasia is detected (the diagnosis must be confirmed by two experienced pathologist) → esophagectomy with removal of all columnar lined epithelium
or
if resection is not done, then the patient should be strictly followed at 3 monthly interval. If cancer is detected resection is done.
Rationale for esophagectomy in high grade dysplasia is based on the following considerations-
(a) cancer is already present in about 30 to 50% of patients operated for high grade dysplasia.
(b) cancer develops in about 50% fo patients during follow up.)
Category:
Surgery
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