DISCUSSION
Based on the esophageal glandular mucosa with intestinal metaplasia, the diagnosis was Barrett's esophagus (BE). Preserved villous architecture on all three small bowel biopsies and a negative result on anti-tTG determination ruled out celiac sprue. Eosinophilic esophagitis was ruled out by the pathology and clinical history.
In BE, abnormal intestinal-type epithelium, referred to as intestinal metaplasia, replaces the squamous epithelium that normally lines the distal esophagus. A consequence of chronic GERD, BE places the patient at increased risk for adenocarcinoma of
the esophagus.1 The reliability of identifying BE on endoscopy is approximately 80%.2 Diagnosis requires endoscopic documentation of columnar epithelium lining the distal esophagus and histologic confirmation of specialized intestinal metaplasia. Endoscopically, the columnar epithelium appears salmon in color, whereas the squamous epithelium has a pale glossy appearance (Figure 1).
The management of BE requires treating the underlying reflux, endoscopic surveillance to detect dysplasia, and treatment of dysplasia. Reflux is traditionally treated with dietary modifications and proton pump inhibitors. A small percentage of patients may elect fundoplication, but fundoplication has a relatively high failure rate and has not been shown to be more effective in preventing cancer than medical therapy.1 The American College of Gastroenterology recommends regular surveillance endoscopy beginning within 6 months to 1 year of a BE diagnosis. If two endoscopies are negative for dysplasia, screening can be done every 3 years.
Treatment Our patient was treated with a proton pump inhibitor and lifestyle changes. He returns for regular office visits to monitor treatment and will undergo surveillance endoscopy in 6 months. JAAPA
Corri Wolf practices at Long Island Gastroenterology in Merrick, New York, and is assistant professor in the PA program at the New York Institute of Technology, Old Westbury, New York. The author has indicated no relationships to disclose relating to the content of this article.
Erich Fogg, PA-C, MMSc, department editor
REFERENCES
1. Wang KK, Sampliner RE. Updated guidelines 2008 for the diagnosis, surveillance and therapy of Barrett's esophagus. Am J Gastroenterol. 2008;103(3):788-797.
2. Kim SL, Waring JP, Spechler SJ, et al. Diagnostic inconsistencies in Barrett's esophagus. Department of Veterans Affairs Gastroesophageal Reflux Study Group. Gastroenterology. 1994;107(4):945-949.