A 62-year-old man comes to the office due to burning discomfort in his chest, which has been getting worse over the last year. The discomfort occurs 4 or 5 times a week, usually 30-40 minutes after meals. The patient has reduced his intake of coffee because he thinks it provokes the symptoms. Other issues include chronic back pain, dry cough, and constipation. The patient has good exercise tolerance and is not limited by chest pain or shortness of breath. He has had no abdominal pain, vomiting, black stools, or weight loss. Medications include daily aspirin and a multivitamin. His father died of pancreatic cancer at age 55. The patient has a 20-pack-year smoking history but quit 5 years ago. Blood pressure is 133/90 mm Hg and pulse is 76/min. BMI is 32 kg/m². Waist circumference is 110 cm. Physical examination is otherwise unremarkable. Upper gastrointestinal endoscopy is indicated to evaluate for which of the following in this patient?

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Explanation: 11ec2b69_bf38_2196_8f63_a9a5b7767b9b_MD0005_00 This patient has multiple risk factors for Barrett esophagus, which is the metaplastic replacement in the lower esophagus of normal stratified squamous epithelium with columnar epithelium (that normally lines the intestines) in response to chronic gastric acid exposure. The condition predisposes to the development of esophageal adenocarcinoma; therefore, most guidelines suggest that patients with a history of chronic gastroesophageal reflux disease (>5 years) or frequent reflux symptoms (eg, heartburn) and ≥2 risk factors should be considered for endoscopic screening. Risk factors include: lower esophagus Age >50 Male sex Caucasian Hiatal hernia Obesity or increased waist circumference (>102 cm) Current or former tobacco use First-degree relative with Barrett esophagus or esophageal adenocarcinoma Patients who have a positive screening test without evidence of high-grade dysplasia should undergo continued endoscopic screening and acid suppression with a once-daily proton pump inhibitor. Those with high-grade dysplasia should be considered for endoscopic eradication therapy. (Choice B) In the United States, endoscopic screening for gastric cancer is performed only in patients at very elevated risk (eg, those with Lynch syndrome). Diagnostic endoscopy would be indicated in patients with symptoms suggestive of gastric cancer (eg, weight loss, anorexia, abdominal pain), but this patient does not have these symptoms. (Choices C and E) Upper endoscopy is indicated in patients age >60 with new-onset dyspepsia (eg, postprandial fullness, early satiety, epigastric pain) to evaluate for Helicobacter pylori infection or complications of peptic ulcer disease. However, this patient's heartburn that worsens after he drinks coffee is more consistent with gastroesophageal reflux than dyspepsia. (Choice D) Endoscopy is not required to diagnose reflux esophagitis. However, if patients undergo endoscopy for other indications (eg, screening for Barrett esophagus) and severe erosive esophagitis is noted, repeat endoscopy may be warranted after a trial of proton pump inhibitor therapy. Educational objective: Barrett esophagus develops in response to chronic gastric acid exposure, predisposing to esophageal adenocarcinoma. Patients with a history of chronic gastroesophageal reflux disease (>5 years) or frequent symptoms and ≥2 risk factors (eg, male sex, central obesity) should be considered for endoscopic screening. References: ACG clinical guideline: diagnosis and management of Barrett's esophagus. (http://www.ncbi.nlm.nih.gov/pubmed/26526079)

A 62-Year-Old Man Comes to the Office Due to Burning