Barrett's esophagus is a premalignant condition where the normal squamous epithelium of the esophagus is replaced by columnar epithelium, usually as a result of chronic gastroesophageal reflux disease. It is a risk factor for esophageal adenocarcinoma. Screening for Barrett's esophagus is recommended for men over 50 with chronic GERD symptoms. Treatment options for dysplasia include endoscopic ablation or resection. Esophageal cancer is often diagnosed via endoscopy and has a poor prognosis depending on stage. Risk factors include tobacco, alcohol, GERD, and obesity.

1. Barrets & Ca esophagusBarrets & Ca esophagus
Professor Dr.MohamedProfessor Dr.Mohamed
AlshekhaniAlshekhani
20182018

2. Barrett EsophagusBarrett Esophagus
 Present when columnar epithelium replacesPresent when columnar epithelium replaces
the normal squamous epithelium in the distalthe normal squamous epithelium in the distal
esophagus.esophagus.
 A consequence of GERD whether or notA consequence of GERD whether or not
clinicalyclinicaly
symptomaticsymptomatic
 Risk factors:Risk factors:
 Older age, male, white ethnicity, GERD, HH,Older age, male, white ethnicity, GERD, HH,
highhigh
BMI, smoking,abdominal obesity.BMI, smoking,abdominal obesity.
 Protective factors:Protective factors:
 Moderate wine consumptionModerate wine consumption

3. Barrett EsophagusBarrett Esophagus
 A premalignant condition that could progress to EAC.A premalignant condition that could progress to EAC.
 Annual incidence of progression to high-gradeAnnual incidence of progression to high-grade
dysplasia & adenocarcinoma 0.12-0.5°/o / year,dysplasia & adenocarcinoma 0.12-0.5°/o / year,
 10% of patients with GERD have BE on OGD,10% of patients with GERD have BE on OGD,
 40% diagnosed with EAC have no GERD symptoms40% diagnosed with EAC have no GERD symptoms

4. Screening:Screening:
 No routine screening for BE based on GERDNo routine screening for BE based on GERD
symptoms.symptoms.
 Only in men >50 years with chronic GERD symptomsOnly in men >50 years with chronic GERD symptoms
for > 5 years& additional risk factors; nocturnalfor > 5 years& additional risk factors; nocturnal
reflux symptoms, hiatal hernia, elevated BMI, tobaccoreflux symptoms, hiatal hernia, elevated BMI, tobacco
use, abd obesity.use, abd obesity.
 If screening is performed&negative for BE, noIf screening is performed&negative for BE, no
additionaladditional
screening is indicated,even for patients continuingscreening is indicated,even for patients continuing
treatmenttreatment
for GERD, unless other symptoms or clinical findingsfor GERD, unless other symptoms or clinical findings
develop.develop.

5. Diagnosis:Diagnosis:
 OGD findings of (salmon-colored mucosa comparedOGD findings of (salmon-colored mucosa compared
withwith
normal pearl colored squamous mucosa) above thenormal pearl colored squamous mucosa) above the
normallynormally
located GEJ&histologicly confirmed to be columnarlocated GEJ&histologicly confirmed to be columnar
epitheliumepithelium
 BE:short segment (<3 cm) or long segment (> 3 cm).BE:short segment (<3 cm) or long segment (> 3 cm).
 The pathway of progression of BE is from intestinalThe pathway of progression of BE is from intestinal
metaplasia to low-grade dysplasia to high-grademetaplasia to low-grade dysplasia to high-grade
dysplasia to invasive adenocarcinoma.dysplasia to invasive adenocarcinoma.
 Recommended surveillance intervals are based onRecommended surveillance intervals are based on
thethe
grade of BE & the presence of dysplasia.grade of BE & the presence of dysplasia.
 The potential risks / benefits of surveillance shouldThe potential risks / benefits of surveillance should

7. Treatment:Treatment:
 Treatment to remove Barrett esophagus isTreatment to remove Barrett esophagus is
recommendedrecommended
for patients with confirmed high-grade dysplasia byfor patients with confirmed high-grade dysplasia by
endoscopic (RFA ablation, photodynamic therapy,endoscopic (RFA ablation, photodynamic therapy, oror
EMR).EMR).
 Chemoprevention with PPI, aspirin or NSAID therapy,Chemoprevention with PPI, aspirin or NSAID therapy,
oror
antireflux surgery has not been definitively shown toantireflux surgery has not been definitively shown to
decrease the risk of progression of dysplasia ordecrease the risk of progression of dysplasia or
development ofdevelopment of
adenocarcinoma in patients with BEadenocarcinoma in patients with BE

8. Esophageal cancerEsophageal cancer
 6th leading cause of cancer-related mortality6th leading cause of cancer-related mortality
worldwide.worldwide.
 The most common types are SCC& EAC; former > inThe most common types are SCC& EAC; former > in
developing world while latter is more common in thedeveloping world while latter is more common in the
west.west.
 Esophageal cancer has a male predominance, oftenEsophageal cancer has a male predominance, often
in 5in 5thth
-6-6thth
decades of life,more common in black men.decades of life,more common in black men.
 The overall 5-year survival rate is between 15-25%,The overall 5-year survival rate is between 15-25%,
depending on stage at time of initial diagnosis.depending on stage at time of initial diagnosis.

10. Esophageal SCC: RFsEsophageal SCC: RFs
 TobaccoTobacco
 AlcoholAlcohol
 Caustic injuryCaustic injury
 AchalasiaAchalasia
 Past thoracic radiationPast thoracic radiation
 Nutritional deficiencies (zinc, selenium)Nutritional deficiencies (zinc, selenium)
 Poor socioeconomic status,Poor socioeconomic status,
 Poor oral hygiene,Poor oral hygiene,
 Nonepidermolytic palmoplantar keratoderma (tylosis),Nonepidermolytic palmoplantar keratoderma (tylosis),
 HPV infectionHPV infection
 Nitrosamine exposure.Nitrosamine exposure.

12. Esophageal EAC: RFsEsophageal EAC: RFs
 GERDGERD
 BEBE
 ObesityObesity
 Tobacco useTobacco use
 Past thoracic radiationPast thoracic radiation
 Diet low in fruits / vegetablesDiet low in fruits / vegetables
 Increased ageIncreased age
 Male sex,Male sex,
 ? medications that relax the LES.? medications that relax the LES.

14. Esophageal Cancer:Esophageal Cancer:
symptomssymptoms
 The most common clinical manifestation is solid-foodThe most common clinical manifestation is solid-food
dysphagia.dysphagia.
 Upper endoscopy with biopsy is the preferred initialUpper endoscopy with biopsy is the preferred initial
diagnostic test for esophageal carcinoma.diagnostic test for esophageal carcinoma.
 Can be diagnosed in asymptomatic individuals duringCan be diagnosed in asymptomatic individuals during
surveillance upper endoscopy.surveillance upper endoscopy.
 Other symptoms include weight loss. anorexia,Other symptoms include weight loss. anorexia,
anemia.anemia.
 SCC is located in the proximal esophagus.SCC is located in the proximal esophagus.
 EAC is usually found in distal esophagus.EAC is usually found in distal esophagus.
 TNM staging is often done with CT scan (to evaluateTNM staging is often done with CT scan (to evaluate
forfor