Barrett’s oesophagus

48 yr male with no co-morbidity undergoes OGD for dyspepsia and heartburn. On endoscopy he had features of grade 2 esophagitis and a patch of red mucosa. Biopsy reveals presence of goblet cells with in columnar epithelium and mild dysplasia. Further management should be:

 

discuss in MDT for oesophagectomy 

repeat OGD in 3 months

list him for annual surveillance

list him for bi-annual surveillance

 

Also know as Columnar lined oesophagus (CLO) defined as oesophagus in which any portion of the normal oesophagus is replaced by macroscopically visible metaplastic columnar epithelium. This must be visible above OG junction.(1)

 

To recognise Barrett’s mucosa it is essential to identify OG junction. When the red looking mucosa is seen proximal to OG junction, one should suspect this to be columnar epithelium and should be biopsied. (2)

 

 

Normal pale looking sqamous mucosa merges into red columnar epithelium at OG junction. OG junction is defined at the level of most proximal gastric fold. It should be recognised on endoscopy with lumen deflated.(1)

 

Columnar lined oesophagus can often be confused with gastric mucosa. Hence it is important for the pathologist to know the site from where biopsies have been taken, its distance from incisors and relation to OG junction. The diagnosis of CLO can only be confirmed on histology by presence of native oesophageal structures (seen in 15% cases)or features of intestinal metaplasia (seen in 1 in 6 cases) on histology. According to BSG guidelines the pathologist should report the biopsy in any of the 4 categories:

1 Biopsies diagnostic of CLO

2 Biopsies corroborative of an endoscopic diagnosis of CLO, if taken from the anatomical oesophagus

3 Biopsies in keeping with, but not specific for, CLO, if taken from the anatomical oesophagus.

4 Biopsies without evidence of CLO.

 

Management of Barrett’s depends on presence or absence of dysplasia. All patients with non-dysplastic Barrett’s should be considered for surveillance. If symptomatic, they should also receive PPI to treat gastro-oesophageal reflux.

 

CLO is considered as pre-malignant lesion. leading to oesophageal adenocarcinoma. However, dysplasia develops in 5 % of patients and of these, 10-50% may progress to high grade dysplasia and adenocarcinoma over 2- 5 years.(1)

 

All patients with non-dysplatic CLO should have surveillance OGD once in 2 years.

On OGD quadrantic biopsies should be taken every 2cm in the columnar segment together with biopsies of any visible lesion.(1)

 

No, there isn’t enough evidence available to support fundoplication to prevent progress of CLO to dysplasia and malignancy. The indications of surgery are same as for symptomatic GORD.(1)

 

No, there isn’t enough evidence available to recommend OGD.(1)

 

They should receive a 12 weeks course of intensive acid suppression therapy with PPI and have a repeat biopsy in 3 months. If the diagnosis is confirmed, the frequency of endoscopic surveillance should be reduced to 6 monthly intervals.(1)

 

Presence of high grade dysplasia is associated with a focus of invasive adenocarcinoma in 30-40% cases. Hence, the diagnosis should be confirmed by a second pathologist and provide the patient is fit, he should be considered for oesophagectomy. Those who unfit for surgery should be offered endoscopic ablation or mucosal resection.(1)

 

Achlasia cardia

Tylosis

Plummer-Vinson syndrome

Pharyngeal diverticulum

Corrosive stricture

References:

1) BSG guidelines: http://www.bsg.org.uk/pdf_word_docs/Barretts_Oes.pdf

2) ACG guidelines: http://www.acg.gi.org/physicians/guidelines/BarrettsEsophagus.pdf