A 61-year-old man presents to his gastroenterologist for a follow-up visit. He has a 15-year history of gastroesophageal reflux disease that is well controlled with a proton pump inhibitor. Five years ago, he was diagnosed with Barrett esophagus during evaluation of chronic reflux symptoms and has undergone periodic surveillance endoscopy since that time. He currently feels well and denies dysphagia, odynophagia, weight loss, or gastrointestinal bleeding. Physical examination is unremarkable. Upper endoscopy demonstrates a segment of salmon-colored mucosa in the distal esophagus. Biopsies reveal intestinal metaplasia with high-grade dysplasia. No invasive carcinoma is identified.
Which of the following is the most appropriate next step in management?
The correct answer is:
A) Endoscopic eradication therapy
This patient has Barrett esophagus with high-grade dysplasia, which carries a substantial risk of progression to esophageal adenocarcinoma. The most appropriate management is endoscopic eradication therapy, typically using endoscopic mucosal resection of visible lesions combined with radiofrequency ablation of remaining dysplastic Barrett mucosa.
Barrett esophagus develops when chronic gastroesophageal reflux leads to replacement of the normal squamous epithelium of the distal esophagus with specialized intestinal-type columnar epithelium. This metaplastic change increases the risk of progression through a dysplasia-carcinoma sequence:
Step 2 commonly tests management based on pathology findings rather than symptoms. Patients with high-grade dysplasia require definitive treatment because the risk of occult carcinoma or progression to invasive cancer is significant. Modern endoscopic eradication techniques are highly effective and are generally preferred over surgical management when invasive cancer is not present.
Answer choice B: Esophagectomy for all patients with Barrett esophagus, is incorrect.
Esophagectomy is not indicated for uncomplicated Barrett esophagus and is no longer the preferred treatment for most patients with high-grade dysplasia. Endoscopic eradication therapy is less invasive and has excellent outcomes when invasive cancer is absent.
Answer choice C: Repeat endoscopy in 10 years, is incorrect.
A 10-year surveillance interval is inappropriate in a patient with high-grade dysplasia. Delaying treatment would expose the patient to a substantial risk of progression to adenocarcinoma.
Answer choice D: Repeat endoscopy only if symptoms develop, is incorrect.
Progression from Barrett esophagus to adenocarcinoma can occur without new symptoms. Management is based on histology, not symptom development.
Answer choice E: Switch from a proton pump inhibitor to an H2-receptor antagonist, is incorrect.
Acid suppression helps control reflux symptoms but does not adequately address high-grade dysplasia. This patient requires definitive treatment of the dysplastic tissue.
Key Learning Point
Barrett esophagus with high-grade dysplasia requires endoscopic eradication therapy because of the substantial risk of progression to esophageal adenocarcinoma. Management is determined by histologic findings rather than symptom severity.
