From the Guidelines
I strongly recommend continuing proton pump inhibitor (PPI) therapy, such as omeprazole 40mg daily or equivalent, for this 62-year-old male with Barrett's esophagus and GERD presenting with stomach discomfort, as it reduces acid exposure and may help prevent progression to dysplasia by minimizing ongoing inflammation 1.
Patient Management
The patient's recent EGD confirms Barrett's metaplasia without dysplasia, which requires ongoing surveillance.
- He should schedule a follow-up EGD in 3-5 years given the absence of dysplasia, as the risk of progression to high-grade dysplasia or cancer is lower in patients with short-segment Barrett's esophagus without dysplasia 1.
- For symptom management, consider lifestyle modifications including:
- Weight loss if overweight
- Avoiding meals within 3 hours of bedtime
- Elevating the head of the bed 6-8 inches
- Avoiding trigger foods (spicy, fatty, acidic foods, chocolate, caffeine, and alcohol)
- If symptoms persist despite PPI therapy, consider adding an H2 blocker like famotidine 20mg at bedtime for breakthrough symptoms.
Surveillance and Follow-up
The patient should report any new symptoms such as dysphagia, weight loss, or worsening pain promptly, as these could indicate disease progression requiring earlier evaluation.
- The British Society of Gastroenterology guidelines suggest that the length of Barrett's esophagus is associated with the risk of progression to high-grade dysplasia or cancer, and that patients with short-segment Barrett's esophagus have a lower risk of progression 1.
- However, the patient's individual risk factors and symptoms should be taken into account when determining the frequency of surveillance and follow-up.
From the Research
Patient's Condition
The patient is a 62-year-old male with a history of Barrett's esophagus and GERD, presenting with stomach discomfort. His last EGD on 12.06.2023 showed squamous and glandular mucosa with mild chronic inflammation, intestinal metaplasia (Barrett's metaplasia) present, and no dysplasia or malignancy identified.
Treatment and Management
- The treatment of patients with Barrett's esophagus is similar to that of any patient with underlying gastroesophageal reflux disease (GERD) 2.
- Medical therapy includes the use of a proton pump inhibitor to treat the underlying GERD, with the goal of controlling reflux symptoms or esophageal pH 2.
- Proton pump inhibitors have been shown to be effective and safe agents for the treatment of GERD, with long-term follow-up data indicating their effectiveness over more than a decade 3.
- The use of proton pump inhibitors may also have a cancer-protective effect in patients with Barrett's esophagus, by eliminating chronic esophageal inflammation and decreasing esophageal exposure to acid 4.
Surveillance and Monitoring
- Surveillance endoscopy with biopsy is the standard approach to monitoring patients with Barrett's esophagus, to detect dysplasia and prevent progression to adenocarcinoma 2.
- The American College of Gastroenterology recommends endoscopic eradication therapy for patients with BE and high-grade dysplasia, and those with BE and low-grade dysplasia 5.
- Structured surveillance intervals are proposed for patients with dysplastic BE after successful ablation, based on the baseline degree of dysplasia 5.
Prognosis and Risk
- The overall cancer risk in patients with Barrett's esophagus is lower than previously estimated, at approximately 0.5% annually 3.
- Short-segment Barrett's esophagus is associated with an increased risk of dysplasia or cancer, similar to that of long-segment Barrett's esophagus 3.
- The risk of adenocarcinoma in patients with Barrett's esophagus can be mitigated with proper surveillance and monitoring, and treatment with proton pump inhibitors may have a cancer-protective effect 4.