A 54-year-old man is evaluated for worsening upper abdominal discomfort and heartburn. For the last 5 years, his occasional midepigastric pain after meals and at night was relieved by over-the-counter ranitidine. Over the last 6 months, the patient's symptoms have occurred almost daily and are not relieved by ranitidine. He has had no dysphagia, odynophagia, hematemesis, melena, or weight loss. He has a 40-pack-year smoking history.
Vital signs are within normal limits. BMI is 29 kg/m². The abdomen is soft and nontender. Stool occult blood testing is negative.
Upper gastrointestinal endoscopy shows moderate esophagitis with red, velvety mucosa extending from the gastroesophageal junction into the distal esophagus. There is a moderate hiatal hernia but no erythema or ulcers in the stomach or duodenum. Biopsy shows Barrett esophagus with high-grade dysplasia.
In addition to daily proton pump inhibitor therapy, which of the following is the best next step in management of this patient?

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Quizplus · Accepted Answer

11ec193a_9819_11a5_853d_b52b9bcd245b_MD0002_00 Barrett esophagus is replacement in the esophagus of normal stratified squamous epithelium with metaplastic columnar epithelium; the condition predisposes to the development of esophageal adenocarcinoma, especially in men. Consequently, men with a history of chronic gastroesophageal reflux disease (>5 years) or frequent reflux symptoms (eg, heartburn) and ≥2 risk factors (eg, obesity, tobacco use) should be considered for endoscopic screening. Columnar epithelium on endoscopy is usually salmon-colored with a velvety texture; squamous epithelium has a pale and glossy appearance. Following initial endoscopy, patients without macroscopic evidence of Barrett esophagus can undergo routine surveillance endoscopy in 3-5 years (Choice E). Those with evidence of Barrett esophagus need further histologic evaluation for dysplasia and should receive a daily proton pump inhibitor to decrease symptoms, heal esophagitis, and possibly decrease the progression to cancer. salmon-colored Histologically confirmed low-grade dysplasia can be managed by endoscopic eradication therapy (eg, ablation, mucosal resection) or surveillance endoscopy every 6-12 months (Choice C). Confirmed high-grade dysplasia should be managed with endoscopic eradication therapy or esophagectomy; endoscopic eradication is less invasive and is preferred in most patients. (Choice A) Helicobacter pylori infection has not been associated with Barrett esophagus and should not be empirically treated without evidence of infection. (Choice D) Surgical fundoplication is considered in patients who have persistent gastroesophageal reflux disease symptoms despite maximal medical therapy (ie, twice-daily proton pump inhibitor). It is not indicated in the management of Barrett esophagus. Educational objective: Patients with Barrett esophagus and high-grade dysplasia require endoscopic eradication therapy (preferred) or esophagectomy. __________ References: ACG clinical guideline: diagnosis and management of Barrett's esophagus. (http://www.ncbi.nlm.nih.gov/pubmed/26526079) Common questions about Barrett esophagus. (http://www.ncbi.nlm.nih.gov/pubmed/24444576)

A 54-Year-Old Man Is Evaluated for Worsening Upper Abdominal Discomfort