Under what circumstances should a 41-year-old female with two first-degree relatives with Barrett's esophagus and a 10 pack-year (packs per year) history of smoking be screened with an Esophagogastroduodenoscopy (EGD)?

From the Guidelines

Screening with an Esophagogastroduodenoscopy (EGD) is not routinely recommended for a 41-year-old female with two first-degree relatives with Barrett's esophagus and a 10 pack-year smoking history. Current guidelines do not support EGD screening based solely on family history of Barrett's esophagus or smoking history, as stated in the guidelines from the American College of Physicians 1. Instead, EGD screening should be considered if this patient develops chronic gastroesophageal reflux disease (GERD) symptoms such as heartburn, regurgitation, or chest pain that persist despite 4-8 weeks of appropriate proton pump inhibitor therapy (such as omeprazole 20-40 mg daily or esomeprazole 40 mg daily) 1. Additional concerning symptoms that would warrant EGD include dysphagia (difficulty swallowing), odynophagia (painful swallowing), unintentional weight loss, persistent vomiting, or evidence of gastrointestinal bleeding. While family history of Barrett's esophagus does increase risk, it alone is not sufficient to justify invasive screening in the absence of symptoms. The patient should be counseled on smoking cessation, as continued smoking increases risk for both Barrett's esophagus and esophageal cancer, and lifestyle modifications to reduce reflux symptoms, including weight loss if overweight, avoiding late meals, and elevating the head of the bed.

Some key points to consider:

• The patient's age and sex do not warrant routine screening for Barrett's esophagus, as the incidence of esophageal adenocarcinoma is low in women and younger patients 1.
• The presence of GERD symptoms, such as heartburn and regurgitation, is a more significant risk factor for Barrett's esophagus than family history or smoking history alone 1.
• If the patient develops symptoms or has a history of GERD, EGD screening may be considered, but the decision should be individualized and based on the patient's overall risk profile 1.
• The American Gastroenterological Association and the American College of Gastroenterology have published guidelines for the diagnosis and management of Barrett's esophagus, which emphasize the importance of individualized decision-making and consideration of the patient's overall risk profile 1.

From the Research

Screening Recommendations for Barrett's Esophagus

The user's question pertains to the screening recommendations for a 41-year-old female with two first-degree relatives with Barrett's esophagus and a 10 pack-year history of smoking.

• Family History and Smoking: The presence of two first-degree relatives with Barrett's esophagus and a history of smoking are significant risk factors for the development of Barrett's esophagus and esophageal adenocarcinoma 2.
• Screening Modalities: Esophagogastroduodenoscopy (EGD) is the primary screening modality for Barrett's esophagus. However, other modalities such as esophageal capsule endoscopy (ECE) have been explored, but its accuracy is moderate and it is not suitable as a primary screening tool 3.
• Screening Guidelines: The American College of Gastroenterology recommends screening for Barrett's esophagus in patients with multiple risk factors, including a family history of Barrett's esophagus or esophageal adenocarcinoma, and a history of smoking 4, 2.
• Surveillance Intervals: For patients with Barrett's esophagus without dysplasia, surveillance endoscopy is recommended at intervals of 3 to 5 years 2. However, the optimal surveillance interval for patients with a family history of Barrett's esophagus and a history of smoking is not well established.

Considerations for Screening

• Risk of Esophageal Adenocarcinoma: The annual risk of esophageal cancer is approximately 0.25% for patients without dysplasia and 6% for patients with high-grade dysplasia 2.
• Effectiveness of Surveillance: Endoscopic surveillance after successful ablation of baseline high-grade dysplasia or intramucosal cancer is more effective than surveillance after successful treatment of baseline low-grade dysplasia in averting invasive adenocarcinoma 5.
• Patient Selection: Patients with a family history of Barrett's esophagus and a history of smoking may benefit from earlier and more frequent screening, but the optimal approach is not well established and requires further study.

Summary of Key Points

• A 41-year-old female with two first-degree relatives with Barrett's esophagus and a 10 pack-year history of smoking is at increased risk for Barrett's esophagus and esophageal adenocarcinoma.
• EGD is the primary screening modality for Barrett's esophagus.
• Screening guidelines recommend screening for patients with multiple risk factors, but the optimal surveillance interval for this patient is not well established.
• Endoscopic surveillance is more effective for patients with high-grade dysplasia or intramucosal cancer than for those with low-grade dysplasia.