Barretts oesophagus

Question 1

What is Barrett’s oesophagus?

Answer 1

Condition where metaplastic columnar epithelium replacing the normal stratified squamous epithelium of the distal oesophagus

Develops in response to chronic exposure to gastro-oesophageal reflux and predisposes to adenocarcinoma of the oesophagus.

Question 2

What are the types of metaplastic columnar epithelium in Barrett’s oesophagus?

Answer 2

• Gastric-fundic type
• Cardiac type
• Intestinal type

Australian guidelines require the presence of intestinal type metaplasia for the diagnosis of BE.

Question 3

What does SIM stand for in the context of Barrett’s oesophagus?

Answer 3

Specialised Intestinal Metaplasia

Question 4

What is the global prevalence of Barrett’s oesophagus?

Answer 4

Globally prevalence low (<5%)

Higher in select groups such as those with GORD (>15%).

Question 5

How does ethnicity affect the prevalence of Barrett’s oesophagus?

Answer 5

Prevalence varies by ethnicity, with <1% in the Asian population.

Question 6

Which gender is more commonly affected by Barrett’s oesophagus?

Answer 6

More common in males

Question 7

What was the prevalence of Barrett’s oesophagus in the Swedish study of 3000 people?

Answer 7

1.6% despite GORD rate of 40% and 15% with oesophagitis.

Question 8

What percentage of people with Barrett’s oesophagus had no reflux symptoms in the preceding 3 months in the Swedish study?

Answer 8

44%

Question 9

What percentage of people with reflux had Barrett’s oesophagus according to the Swedish study?

Answer 9

2.3%

Not statistically different from baseline rate.

Question 10

True or False: Other studies have shown increased prevalence of Barrett’s oesophagus with a history of reflux.

Answer 10

True

Question 11

What are the non-modifiable risk factors for Barrett’s?

Answer 11

Age, Male Sex, Family hx

Family hx refers to family history of Barrett’s or related conditions.

Question 12

List the modifiable risk factors for Barrett’s.

Answer 12

GORD, Central Obesity, Smoking

GORD stands for Gastroesophageal Reflux Disease.

Question 13

True or False: Smoking is a non-modifiable risk factor for Barrett’s.

Answer 13

False

Smoking is classified as a modifiable risk factor.

Question 14

Fill in the blank: _______ is a modifiable risk factor for Barrett’s associated with weight distribution.

Answer 14

Central Obesity

Central obesity refers to excess fat around the stomach area.

Question 15

Which gender is identified as a non-modifiable risk factor for Barrett’s?

Answer 15

Male Sex

Males are at a higher risk for developing Barrett’s compared to females.

Question 16

What are the major non-modifiable risk factors for Barrett’s oesophagus?

Answer 16

Age, Male Sex, Family hx

Family hx refers to family history of related conditions.

Question 17

What are the major modifiable risk factors for Barrett’s oesophagus?

Answer 17

GORD, Central Obesity, Smoking

GORD stands for gastro-oesophageal reflux disease.

Question 18

What is the potential protective effect of past infection with H. pylori?

Answer 18

Atrophic gastritis causes reduction in acid production and reduced acid exposure.

Question 19

Is there evidence that alcohol or dietary factors influence the risk of Barrett’s oesophagus?

Answer 19

No evidence.

Question 20

What pathological change occurs in Barrett’s oesophagus due to chronic exposure to reflux?

Answer 20

Metaplasia occurs as a maladaptive response to inflammation from chronic reflux oesophagitis.

Question 21

What is the reason for reflux in Barrett’s oesophagus?

Answer 21

Loss of mechanisms that prevent reflux.

Question 22

How is mucosal damage from reflux typically repaired in most patients?

Answer 22

By regeneration of more squamous cells.

Question 23

What replaces squamous cells in some patients with Barrett’s oesophagus?

Answer 23

Metaplastic columnar cells.

Question 24

What predisposes Barrett’s patients to develop adenocarcinoma?

Answer 24

Accumulation of genetic mutations leading to progressive dysplastic changes.

Question 25

Does Barrett's oesophagus cause any symptoms?

Answer 25

No symptoms.

Question 26

With which condition is Barrett's oesophagus commonly associated?

Answer 26

GORD - heartburn and regurgitation.

Question 27

What complications can arise from Barrett's oesophagus?

Answer 27

Bleeding from erosions, dysphagia from strictures.

Question 28

How does Barrett’s oesophagus appear endoscopically?

Answer 28

As salmon pink mucosa extending above the GOJ into the tubular oesophagus.

Question 29

What classification is used to describe Barrett’s oesophagus?

Answer 29

Prague Classification C&M criteria.

Question 30

In the Prague Classification, what does 'C' stand for?

Answer 30

Maximum extent of circumferential disease.

Question 31

In the Prague Classification, what does 'M' stand for?

Answer 31

Maximum proximal extent.

Question 32

What defines a short segment of Barrett's oesophagus?

Answer 32

Short Segment >3cm.

Question 33

What defines a long segment of Barrett's oesophagus?

Answer 33

Long Segment <3cm.

Question 34

When should Barrett's be suspected?

Answer 34

When Z-line is more than >1cm proximal to OGJ and has a salmon pink color with a velvet-like texture compared to squamous epithelium's pale, glossy appearance ## Footnote The Z-line is the junction between the squamous epithelium and columnar epithelium of the esophagus.

Question 35

What criteria are used to assess the extent of Barrett's?

Answer 35

Prague C & M criteria ## Footnote The GOJ is the key anatomical landmark defined as the proximal extent of gastric folds.

Question 36

What defines the short segment vs long segment of Barrett's?

Answer 36

Short segment: less than or equal to 3cm; Long segment: greater than 3cm ## Footnote If the Z-line is <1cm with non-circumferential tongues, it's called an irregular Z-line.

Question 37

What is the Seattle Protocol for biopsy in Barrett's?

Answer 37

4 quadrant biopsies every 2cm and a separate biopsy from the anatomic cardia ## Footnote If dysplasia is present, biopsies should be taken at 1cm intervals.

Question 38

What is the minimum number of biopsies required for histological confirmation of Barrett's?

Answer 38

Minimum 8 biopsies required ## Footnote Only 4 biopsies result in Barrett's esophagus being confirmed in 34.7% of cases.

Question 39

What is required for the diagnosis of Barrett's?

Answer 39

Histological diagnosis from biopsies on endoscopy ## Footnote US guidelines require intestinal metaplasia (IM) to diagnose Barrett’s, while British guidelines only require columnar lined mucosa (CLM).

Question 40

What percentage of patients with endoscopically suspected Barrett's had no histological confirmation?

Answer 40

42% had no endoscopic or histologic evidence of Barrett's esophagus ## Footnote 46% had endoscopic appearances consistent with Barrett's but no histologic evidence.

Question 41

What confers the highest known risk of cancer development in Barrett's?

Answer 41

Intestinal metaplasia (IM) ## Footnote In patients with long segment Barrett's (>3cm), IM is almost always found.

Question 42

What is the established role of screening for Barrett's?

Answer 42

No established role ## Footnote Long-segment Barrett's esophagus is found in 3 to 5 percent of patients with chronic GERD symptoms.

Question 43

What factors determine the management of Barrett's?

Answer 43

Presence and degree of dysplasia, length of Barrett's esophagus ## Footnote The absolute risk of esophageal adenocarcinoma in patients with GERD symptoms is low.

Question 44

True or False: Screening patients with GERD symptoms reliably identifies all individuals at high risk for esophageal adenocarcinoma.

Answer 44

False ## Footnote More than 40 percent of patients with esophageal adenocarcinoma have no history of heartburn.

Question 45

What is the incidence of oesophageal cancer in Barrett's esophagus?

Answer 45

0.4-3% incidence per year ## Footnote Barrett's esophagus confers a 30x risk compared to the general population.

Question 46

What is the main goal of managing Barrett's esophagus?

Answer 46

Prevent progression, eradicate disease burden, and avoid development of esophageal cancer.

Question 47

What is the role of PPIs in Barrett's esophagus management?

Answer 47

No strong evidence that treatment reduces risk of progression of IM to HGD or cancer, but one meta-analysis showed an odds ratio of 0.29.

Question 48

What did a randomized trial show regarding H2-blockers in Barrett's esophagus?

Answer 48

Regression with twice daily PPI, no regression in H2-blocker group.

Question 49

What was the outcome of the Celecoxib vs placebo study?

Answer 49

No difference in progression to HGD or cancer.

Question 50

What is the current evidence regarding antireflux surgery in Barrett's esophagus?

Answer 50

No high-quality evidence to support its use to prevent progression.

Question 51

What is the recommended surveillance for no dysplasia in Barrett's esophagus?

Answer 51

Surveillance scope in 2-3 years (>3cm) or 3-5 years (<3cm).

Question 52

What should be done if indefinite dysplasia is found?

Answer 52

Re-scope in 6 months; 60% had no dysplasia at follow-up.

Question 53

How often should low-grade dysplasia be monitored?

Answer 53

Repeat endoscopy every 6-12 months with 1cm biopsies.

Question 54

What is the role of RFA in low-grade dysplasia?

Answer 54

May be useful to prevent progression to HGD (0.8% vs 6.6%).

Question 55

What is the management for high-grade dysplasia?

Answer 55

Repeat endoscopy as soon as possible, with high-resolution endoscopy and 1 cm biopsies.

Question 56

What was traditionally offered to patients with high-grade dysplasia?

Answer 56

Oesophagectomy.

Question 57

What is the current indication for oesophagectomy?

Answer 57

Reserved for T1b disease, multifocal carcinoma, or lesions not amenable to endoscopic resection.

Question 58

What are the types of endoscopic resection?

Answer 58

EMR or ESD.

Question 59

What is RFA and how is it applied?

Answer 59

Uses radiofrequency energy applied via a coiled electrode array to ablate the mucosal epithelium.

Question 60

What is the re-scoping timeline after RFA?

Answer 60

12 weeks later, with PPI and EtOH abstinence.

Question 61

What is the eradication rate of HGD using RFA compared to sham?

Answer 61

81% vs 19%.

Question 62

What is the cancer rate in RFA treatment compared to sham?

Answer 62

1.2% vs 9.3%.

Question 63

What is the pooled adverse reaction rate for RFA?

Answer 63

8.8%.

Question 64

What is the disadvantage of photodynamic therapy compared to RFA?

Answer 64

Inferior to RFA.

Question 65

What does endoscopic surveillance aim to reduce?

Answer 65

Deaths from oesophageal adenocarcinoma.

Question 66

Is there high-quality evidence that surveillance is effective?

Answer 66

No high-quality evidence.

Question 67

What do several small studies suggest about surveillance?

Answer 67

5-year survival is higher in those diagnosed by surveillance compared to those who present with symptoms.

Question 68

What percentage of patients have eradicated specialized intestinal metaplasia (SIM) at 5 years post RFA?

Answer 68

90% ## Footnote RFA stands for radiofrequency ablation.

Question 69

What is the progression rate of Barrett's esophagus (BE) with no dysplasia to high-grade dysplasia or adenocarcinoma in Denmark?

Answer 69

2.2-2.6/1000 person years ## Footnote This rate reflects the risk of progression in a specific population.

Question 70

What is the progression rate of Barrett's esophagus (BE) with no dysplasia to high-grade dysplasia or adenocarcinoma in the UK?

Answer 70

3/1000 person years ## Footnote Indicates a slightly higher risk compared to Denmark.

Question 71

What is the annual progression rate for non-dysplastic Barrett's esophagus?

Answer 71

0.3% per year

Question 72

What is the annual progression rate for short segment Barrett's esophagus?

Answer 72

0.1% per year

Question 73

What is the annual progression rate for low-grade dysplasia in Barrett's esophagus?

Answer 73

1% per year

Question 74

What is the annual progression rate for high-grade dysplasia in Barrett's esophagus?

Answer 74

6-7% per year

Question 75

What are some risk factors for progression of Barrett's esophagus?

Answer 75

* Patient factors (age, sex, obesity, smoking) * Endoscopic appearance (greater segment length, type of Barrett’s, aneuploidy)

Question 76

What effect do regular use of PPI, NSAIDs, and statins have on Barrett's esophagus progression?

Answer 76

May have lower rates of progression

Question 77

How much more likely are patients with Barrett's esophagus to die of other causes than oesophageal adenocarcinoma?

Answer 77

10x more likely