A 52-year-old man is being evaluated due to upper abdominal discomfort, nausea, and frequent heartburn for the past 6 months. His symptoms are partially relieved with over-the-counter antacids. The patient has had no chest pain, dysphagia, odynophagia, vomiting, black or bloody stools, or weight loss. He has a history of hypertension and mild intermittent asthma. He has a 20-pack-year smoking history but quit 3 years ago. BMI is 32.8 kg/m². Upper gastrointestinal endoscopy shows moderate esophagitis with velvety, reddish mucosa extending from the gastroesophageal junction into the distal esophagus and mild antral gastritis. Biopsy results are consistent with Barrett esophagus without dysplasia. Antral mucosal biopsies do not show evidence of Helicobacter pylori infection. He is started on proton pump inhibitor therapy. Which of the following is the best next step in management of this patient?

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Explanation: 11ec2b69_bf1f_1b2c_8f63_d5372f19f280_MD0005_00 Barrett esophagus is characterized by metaplastic columnar epithelium replacing normal stratified squamous epithelium; it is associated with the development of esophageal adenocarcinoma. Most guidelines suggest a screening endoscopy in patients with frequent gastroesophageal reflux disease (GERD) symptoms and ≥2 risk factors for Barrett esophagus (eg, age ≥50, male sex, tobacco use). On endoscopy, squamous epithelium has a pale and glossy appearance, whereas columnar epithelium usually appears reddish (salmon-colored) with a velvet-like texture. appears reddish Esophageal biopsy (4-quadrant biopsies within every 2 cm) is performed in patients with visual evidence of intestinal metaplasia on endoscopy. Patients with intestinal metaplasia without dysplasia on pathologic evaluation can undergo surveillance endoscopy in 3-5 years. Patients with low-grade dysplasia require surveillance endoscopy every 6-12 months or endoscopic eradication therapy (eg, ablation, mucosal resection). High-grade dysplasia is an indication for endoscopic eradication therapy. This patient has Barrett esophagus without dysplasia and requires surveillance endoscopy in 3-5 years. Because there is no high-grade dysplasia, he does not need endoscopic ablative therapy or mucosal resection (Choice A). Proton pump inhibitor (PPI) therapy can decrease the patient's symptoms, heal the esophagitis, and may slow the progression of Barrett esophagus to cancer. (Choice B) Laparoscopic fundoplication is a surgical procedure for treating symptomatic GERD unresponsive to maximal medical therapy (eg, twice-daily PPI); it is not indicated in this patient who has not yet been on PPI therapy. (Choice D) Antral mucosal biopsies are highly sensitive and specific for diagnosing Helicobacter pylori and do not require repeat testing. (Choice E) Surgical esophagectomy is a treatment option for Barrett esophagus with high-grade dysplasia. Although surgery can effectively remove the dysplastic tissue, endoscopic eradication is less invasive and is the preferred approach in most patients. Educational objective: Patients with endoscopic evidence of Barrett esophagus without dysplasia on biopsy can undergo surveillance endoscopy in 3-5 years. Low-grade dysplasia warrants surveillance endoscopy every 6-12 months or endoscopic eradication, whereas high-grade dysplasia is an indication for endoscopic eradication therapy. 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 52-Year-Old Man Is Being Evaluated Due to Upper Abdominal