MKSAP: 70-year-old man with heartburn

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 70-year-old man is evaluated in follow-up for heartburn of 7 years’ duration. He has frequent nocturnal reflux but has not had odynophagia or dysphagia, and his weight has been stable. He was recently started on once-daily omeprazole with good control of his symptoms. He has a 30-pack-year history of cigarette smoking and continues to smoke.

On physical examination, vital signs are normal; BMI is 29. The remainder of the physical examination is normal.

He is concerned about his long-term heartburn symptoms and expresses an interest in further evaluation to assess his risk of cancer because of his prolonged symptoms. Based on his risk factors and after discussing with the patient the benefits and harms of screening endoscopy for Barrett esophagus, upper endoscopy is performed. An area of salmon-colored mucosa is seen in the esophagus, and biopsies confirm Barrett esophagus without dysplasia.

Which of the following is the most appropriate next step in management?

A. Endoscopic ablation
B. Esophagectomy
C. Fundoplication
D. Repeat upper endoscopy in 3 to 5 years

MKSAP Answer and Critique

The correct answer is D. Repeat upper endoscopy in 3 to 5 years.

The most appropriate next step in management is to repeat upper endoscopy in 3 to 5 years. Although there is no evidence of the benefit of endoscopic screening of the general population, endoscopic assessment for Barrett esophagus (BE) in patients with chronic reflux symptoms may be appropriate in specific patients. It is reasonable to consider screening men older than 50 years with gastroesophageal reflux disease (GERD) symptoms for more than 5 years and additional risk factors (nocturnal reflux symptoms, hiatal hernia, elevated BMI, tobacco use, and intra-abdominal distribution of fat) to detect esophageal adenocarcinoma and BE. This patient is male, older than 50 years, overweight, and is an active smoker; therefore, pursuing screening was reasonable in this patient. His endoscopy revealed BE without evidence of dysplasia. BE is thought to be a complication of GERD resulting in a change in the normal squamous lining of the distal esophagus to a specialized columnar epithelium due to the effect of refluxed gastric secretions. BE is a spectrum ranging from no dysplasia to high-grade dysplasia, and some patients progress to esophageal cancer. Recommended surveillance of patients with newly diagnosed BE is based on the presence and degree of dysplasia on biopsy. In those with no dysplasia, surveillance with upper endoscopy is recommended in 3 to 5 years. In patients with low-grade dysplasia, surveillance is more frequent, usually 6 to 12 months following confirmation by an expert pathologist. High-grade dysplasia requires either more aggressive surveillance or treatment to remove BE (such as with endoscopic ablation or esophagectomy).

Patients with BE with high-grade dysplasia are often treated with endoscopic ablation. This patient has BE with no dysplasia, so this therapy is not appropriate at this time.

Esophagectomy should be reserved for patients in whom endoscopic ablation fails or in those with evidence of esophageal cancer.

Fundoplication is the appropriate treatment for GERD in patients who wish to stop taking medication or in those with a poor response to medical therapy. This patient’s symptoms are well controlled on omeprazole, so fundoplication is not appropriate at this time. Fundoplication does not prevent the progression of BE to dysplasia or cancer.

Key Point

  • In patients with Barrett esophagus and no dysplasia, surveillance with upper endoscopy is recommended in 3 to 5 years.

This content is excerpted from MKSAP 17 with permission from the American College of Physicians (ACP). Use is restricted in the same manner as that defined in the MKSAP 16 Digital license agreement. This material should never be used as a substitute for clinical judgment and does not represent an official position of ACP. All content is licensed to on an “AS IS” basis without any warranty of any nature. The publisher, ACP, shall not be liable for any damage or loss of any kind arising out of or resulting from use of content, regardless of whether such liability is based in tort, contract or otherwise.

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