A 49-year-old man comes to the office for evaluation of a dry cough that occurs mainly at night. His symptoms have been present on and off for several years, but he has not been previously evaluated. The patient also reports a frequent sore throat and occasional epigastric discomfort. He has tried a variety of antihistamines and over-the-counter cough medications without relief. Past medical history is notable for obesity and diet-controlled type 2 diabetes mellitus. He does not smoke or drink alcohol. Cardiopulmonary and abdominal examinations are unremarkable. Chest x-ray reveals no abnormalities, and pulmonary function testing is normal. The patient undergoes upper gastrointestinal endoscopy with mucosal biopsies. Microscopic findings on lower esophageal biopsy are shown in the image below. This patient is at highest risk of which of the following complications?

Question

A 49-year-old man comes to the office for evaluation of a dry cough that occurs mainly at night.  His symptoms have been present on and off for several years, but he has not been previously evaluated.  The patient also reports a frequent sore throat and occasional epigastric discomfort.  He has tried a variety of antihistamines and over-the-counter cough medications without relief.  Past medical history is notable for obesity and diet-controlled type 2 diabetes mellitus.  He does not smoke or drink alcohol.  Cardiopulmonary and abdominal examinations are unremarkable.  Chest x-ray reveals no abnormalities, and pulmonary function testing is normal.  The patient undergoes upper gastrointestinal endoscopy with mucosal biopsies.  Microscopic findings on lower esophageal biopsy are shown in the image below.  This patient is at highest risk of which of the following complications?

Quizplus · Accepted Answer

11ec160b_392e_9ce2_9249_659a2ea180ec_MD0001_00 This patient's persistent dry cough, sore throat, and epigastric discomfort is suggestive of gastroesophageal reflux disease. His esophageal biopsy shows intestinal-type columnar epithelium with goblet cells where a normal esophagus would be lined by stratified squamous epithelium. This finding is diagnostic of Barrett esophagus, which is seen when acidic gastric contents enter the esophagus, causing inflammation and subsequent epithelial necrosis. Sustained epithelial damage promotes metaplastic replacement of the normal stratified squamous epithelium with intestinal-type columnar cells. The transition to columnar epithelium may be seen grossly on endoscopy as tongues of beefy red mucosa extending above the lower esophageal sphincter into areas of normal pale pink squamous mucosa. People with severe and long-standing acid reflux are most prone to Barrett esophagus. This metaplasia is hypothesized to be adaptive at first, as intestinal-type epithelium is more resistant to gastric acid. However, it is a major risk factor for esophageal adenocarcinoma, which typically develops from the metaplastic intestinal epithelium in the distal part of the esophagus. (Choices A and D) The major risk factors for squamous cell carcinoma of the esophagus are cigarette smoking and alcohol use. Achalasia, an esophageal motility disorder caused by the loss of ganglion cells in the lower esophagus, also carries an increased risk of squamous carcinoma. (Choices C and E) Crohn disease can affect the esophagus, typically causing patchy inflammation, erosions, ulcers, strictures, and fistulas. Esophageal varices develop in the context of high portal venous pressure, most often due to alcohol-induced or post-viral liver cirrhosis. These conditions are not associated with Barrett esophagus. Educational objective: Barrett esophagus is a metaplastic condition in which the normal squamous epithelium of the distal esophagus is replaced by intestinal-type columnar epithelium. It occurs most often in longstanding acid reflux and is associated with an increased risk of adenocarcinoma.

A 49-Year-Old Man Comes to the Office for Evaluation of a Dry