From the Guidelines
The next step for this 61-year-old gentleman with Barrett's esophagus with low-grade dysplasia would be to repeat upper endoscopy in three months after optimization of acid suppression therapy. The patient has endoscopic findings of grade C esophagitis, a clean-based ulcer at the GE junction, Barrett's esophagus with low-grade dysplasia, and a hiatal hernia. Before considering ablative therapy, it's essential to optimize acid suppression therapy to allow the esophagitis to heal and potentially reduce inflammation that might be contributing to the dysplastic changes. The current dose of omeprazole (mepsil) 20mg daily may be insufficient, and increasing to twice daily dosing would be appropriate, as suggested by 1 and 1.
After three months of optimized therapy, a repeat endoscopy with additional biopsies would help confirm the persistence of low-grade dysplasia, as inflammation can sometimes mimic dysplastic changes. According to 1, radiofrequency ablation should be offered to people with low-grade oesophageal dysplasia diagnosed from biopsy samples taken at two separate endoscopies, with confirmation by two gastrointestinal pathologists.
Key considerations in managing this patient include:
- Optimizing acid suppression therapy to twice daily dosing of a proton pump inhibitor, as recommended by 1
- Repeating upper endoscopy in three months to confirm the persistence of low-grade dysplasia
- Considering radiofrequency ablation if low-grade dysplasia is confirmed on repeat endoscopy after adequate acid suppression, as suggested by 1
- Ensuring that the patient is managed by an endoscopist with expertise in managing Barrett's esophagus-related neoplasia, as recommended by 1.
By following this approach, we can ensure that the patient receives optimal care for his Barrett's esophagus with low-grade dysplasia, minimizing the risk of progression to high-grade dysplasia or esophageal adenocarcinoma, and improving his overall quality of life.
From the FDA Drug Label
Pantoprazole sodium 40 mg and 20 mg once daily were also compared with nizatidine 150 mg twice daily in a US multicenter, double-blind study of 243 patients with reflux symptoms and endoscopically diagnosed EE of grade 2 or above The percentages of patients healed (per protocol, n = 212) are shown in Table 9. Once-daily treatment with pantoprazole sodium 40 mg or 20 mg resulted in significantly superior rates of healing at both 4 and 8 weeks compared with twice-daily treatment with 150 mg of nizatidine.
The patient has been started on mepsil (pantoprazole) 20 milligrams oral daily at the time of his ER visit. Given the diagnosis of grade C esophagitis and the presence of Barrett's esophagus with low-grade dysplasia, optimization of acid suppression therapy is crucial.
- The next step would be to repeat upper endoscopy in three months after optimization of acid suppression therapy to assess the healing of esophagitis and the progression of Barrett's esophagus. 2