From the Guidelines
The next best step is to explore why the patient believes she has Barrett's esophagus, as it is highly unlikely to develop in just 3 months, and reassure her based on her recent normal endoscopy, while also emphasizing the importance of lifestyle modifications and medication adherence. This approach is supported by the latest guidelines, including the 2024 National Institute for Health and Care Excellence (NICE) guidance on monitoring and management of Barrett's oesophagus and stage I oesophageal adenocarcinoma 1. The patient's recent normal endoscopy 3 months prior makes it unlikely that Barrett's esophagus would have developed in such a short timeframe, as it typically develops over years of chronic acid exposure.
The patient's non-compliance with diet and exercise recommendations should be addressed, as lifestyle modifications are crucial in managing GERD symptoms. Repeating an endoscopy now would be unnecessary, expose the patient to procedural risks, and waste healthcare resources given the recent normal findings. The physician should focus on improving medication adherence, such as ensuring the patient is taking omeprazole as prescribed, and lifestyle modifications, including diet and exercise, before considering additional invasive testing.
According to the American College of Physicians (ACP) guidelines, screening upper endoscopy should not be routinely done in women of any age or in men younger than 50 years regardless of GERD symptoms because the incidence of cancer is very low in these populations 1. However, the most recent and highest quality study, the 2024 NICE guidance, should take precedence in guiding clinical decision-making 1.
Key points to consider in managing this patient include:
- The importance of lifestyle modifications, such as diet and exercise, in managing GERD symptoms
- The need to improve medication adherence, including ensuring the patient is taking omeprazole as prescribed
- The low likelihood of Barrett's esophagus developing in just 3 months, making reassurance based on the recent normal endoscopy appropriate
- The potential for health anxiety, misunderstanding, or exposure to misinformation contributing to the patient's belief that she has Barrett's esophagus, which should be explored through conversation.
From the Research
Next Best Step for Patient with Barrett's Esophagus
The patient presents with non-compliance to diet and exercise, but reports having Barrett's esophagus after a normal endoscopy 3 months prior. Given this information, the next best step would be to:
- Confirm the diagnosis of Barrett's esophagus through histological examination of biopsies, as the diagnosis of Barrett's esophagus is histological and should be confirmed by biopsies 2
- Assess the grade of dysplasia, if present, as the rates of progression to cancer depend on the grade of Barrett's dysplasia 3
- Consider advanced endoscopic imaging to increase the efficiency of current endoscopic surveillance, as current guidelines recommend "random" four-quadrant biopsies which may miss areas of endoscopically-inapparent neoplasia 4
- Discuss the importance of compliance with diet and exercise, as well as the need for ongoing surveillance, as the risk of esophageal adenocarcinoma is still present even with treatment 5, 6
- Consider the patient's risk factors for esophageal adenocarcinoma, such as age, sex, and history of GERD, when determining the frequency of surveillance 3
Surveillance and Treatment Options
The patient's surveillance and treatment options would depend on the grade of dysplasia, if present. Options may include:
- Endoscopic surveillance every 3-5 years for non-dysplastic Barrett's esophagus 5, 2
- Endoscopic eradication therapy (EET) for low-grade dysplasia (LGD) or high-grade dysplasia (HGD) 5
- Surgical or endoscopic treatment for HGD, as the 5-year risk of cancer is 60% 2
- Continued surveillance after treatment, as the risk of esophageal adenocarcinoma is still present even with treatment 6