Barrett Esophagus
A 60-year-old man with a 12-year history of nightly heartburn and acid regurgitation presents after two episodes of vomiting small amounts of fresh blood. Haemoglobin is 121 g/L and he is haemodynamically stable. Upper gastrointestinal endoscopy shows salmon-coloured mucosa extending 4 cm proximally from the gastro-oesophageal junction, and biopsies reveal intestinal-type columnar epithelium with goblet cells and no dysplasia. Which of the following is the most likely diagnosis?
- A.Plummer-Vinson syndrome
- B.Erosive reflux esophagitis
- C.Mallory-Weiss tear
- D.Barrett esophagusCorrect
Explanation
Barrett esophagus is defined by the replacement of the normal stratified squamous epithelium of the distal oesophagus with intestinal-type columnar epithelium containing goblet cells, a change termed intestinal metaplasia. It develops as an adaptive response to chronic acid and bile exposure, and the endoscopic hallmark is salmon-coloured mucosa extending proximally from the gastro-oesophageal junction, confirmed histologically. Recognised risk factors are long-standing gastro-oesophageal reflux, male sex, age over 50 years, white ethnicity, central obesity, and smoking, several of which this man has. The clinical importance lies in its role as the sole recognised precursor to oesophageal adenocarcinoma, with progression through low grade to high grade dysplasia; the annual risk of adenocarcinoma is roughly 0.3% to 0.5% in non-dysplastic disease. Management is a proton pump inhibitor plus endoscopic surveillance every three to five years for non-dysplastic Barrett, whereas confirmed dysplasia is treated with endoscopic eradication using radiofrequency ablation with or without endoscopic mucosal resection. Erosive oesophagitis shows linear mucosal breaks rather than metaplastic columnar epithelium and carries no malignant potential. A Mallory-Weiss tear is a mucosal laceration at the gastro-oesophageal junction after retching, producing haematemesis but not metaplasia. Plummer-Vinson syndrome is the triad of iron deficiency anaemia, dysphagia, and a proximal oesophageal web, and it predisposes to squamous cell rather than adenocarcinoma.
Why each option
- A.
- Plummer-Vinson syndrome comprises iron deficiency, dysphagia, and a proximal oesophageal web, and predisposes to squamous cell carcinoma.
- B.
- Erosive oesophagitis produces mucosal breaks and erosions without columnar metaplasia and has no premalignant potential.
- C.
- A Mallory-Weiss tear is a linear mucosal laceration after forceful retching and does not produce metaplastic epithelium.
- D.
- Correct. Intestinal metaplasia with goblet cells in salmon-coloured distal oesophageal mucosa is the defining feature of Barrett esophagus.
Reference: ACG Clinical Guideline: Diagnosis and Management of Barrett's Esophagus, 2022
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