A 65-year-old man with a history of chronic gastroesophageal reflux comes to the clinic due to dysphagia. The patient has had difficulty swallowing foods such as steak or hard-boiled eggs but is able to drink hot tea and coffee without any issues. Increasing the frequency of his proton pump inhibitor to twice daily did not improve symptoms. He has also lost 6.8 kg (15 lb) over the past 4 months. The patient has a history of hypertension, hyperlipidemia, and osteoarthritis. Medications include amlodipine, atorvastatin, and ibuprofen as needed. He drinks 2 or 3 glasses of wine with dinner most nights but does not use tobacco or illicit drugs. Vital signs are within normal limits. BMI is 32 kg/m². Physical examination is unremarkable. Esophagogastroduodenoscopy reveals a 4-cm mass surrounded by a large segment of discolored mucosa in the lower half of the esophagus. Esophagogastrectomy results are shown in the image below: Which of the following is the most likely predisposing factor for this patient's esophageal disease?

Question

Quizplus · Accepted Answer

11ec160b_3943_3677_9249_63c983cf9d4e_MD0001_00 This patient with chronic gastroesophageal reflux disease (GERD) now has dysphagia with solid foods, weight loss, and a mass in his lower esophagus, raising strong suspicion for esophageal adenocarcinoma. Most cases of esophageal adenocarcinoma arise in the setting of Barrett esophagus, a metaplastic condition whereby the normal stratified squamous epithelium in the distal esophagus is replaced with intestine-like columnar cells in response to chronic acidic damage. Although these metaplastic columnar cells are better suited to handle the presence of acid in the distal esophagus, they are also much more likely to become dysplastic and undergo malignant transformation into esophageal adenocarcinoma. Major risk factors for esophageal adenocarcinoma are similar to those that promote Barrett esophagus and include: Chronic GERD Obesity - increases intragastric pressure, frequency of lower esophageal sphincter relaxation, and rates of hiatal hernia, which promote GERD Smoking Use of medications that lower esophageal sphincter pressure (eg, nitroglycerin) Consumption of foods containing nitroso compounds (eg, processed meats) (Choice A) Alcohol is a risk factor for esophageal squamous cell carcinoma, which typically arises in the mid-esophagus from areas of esophageal squamous dysplasia. Alcohol does not appear to increase the risk of Barrett esophagus, and wine may be protective. (Choice B) Aspirin and other nonsteroidal anti-inflammatory drugs may be protective against esophageal cancer, especially in the setting of Barrett esophagus. These drugs may also be protective against colorectal cancer. (Choice C) Helicobacter pylori is an important risk factor for gastric adenocarcinoma and gastric mucosa-associated lymphoid tissue; it does not appear to increase risk for esophageal adenocarcinoma. (Choice E) Thermal injury due to drinking hot beverages may increase the risk of esophageal squamous cell carcinoma but is not clearly associated with esophageal adenocarcinoma. Educational objective: Esophageal adenocarcinoma usually occurs in the distal esophagus due to underlying Barrett esophagus. Long-standing gastroesophageal reflux disease is the most important risk factor. Obesity, smoking, use of medications that lower esophageal sphincter pressure, and consumption of foods containing nitroso compounds also increase the risk. __________ References: Epidemiology, diagnosis, and management of esophageal adenocarcinoma. (http://www.ncbi.nlm.nih.gov/pubmed/25957861) Etiology and prevention of esophageal cancer. (http://www.ncbi.nlm.nih.gov/pubmed/27722152)

A 65-Year-Old Man with a History of Chronic Gastroesophageal Reflux