Gastrointestinal · Year 2 · from Gastrointestinal
Case 2: Barrett's Esophagus
Patient Presentation
Demographics: 58-year-old male
Chief Complaint: Long-standing heartburn with recent difficulty swallowing
History of Present Illness: The patient reports 15 years of heartburn and regurgitation, worse after meals and when lying down. He has used over-the-counter antacids intermittently with partial relief. Over the past 3 months, he has noticed solid foods "getting stuck" in his chest, requiring him to drink water to help them pass.
Past Medical History: Obesity (BMI 34), hypertension, type 2 diabetes
Social History: 20 pack-year smoking history (quit 5 years ago), occasional alcohol use
Physical Examination
- Vital Signs: BP 138/88 mmHg, HR 78 bpm, BMI 34
- General: Obese male in no acute distress
- Abdomen: Soft, obese, non-tender, no masses
- Oropharynx: Normal
Workup and Results
- Upper Endoscopy: Salmon-colored tongues of mucosa extending 4 cm above the gastroesophageal junction; biopsies obtained
- Histopathology: Intestinal metaplasia with goblet cells; no dysplasia identified
Endoscopic image of Barrett's esophagus showing characteristic salmon-colored columnar epithelium extending proximally from the gastroesophageal junction into the normally pale squamous esophagus.
Image Source: Wikimedia Commons, CC BY-SA 3.0
Diagnosis
Barrett's Esophagus without Dysplasia
Clinical Correlation to Histology
The normal esophageal epithelium is stratified squamous non-keratinized, adapted for abrasion resistance. In Barrett's esophagus, chronic acid and bile reflux injury triggers metaplasia - the replacement of squamous epithelium with intestinal-type columnar epithelium containing goblet cells. This represents an adaptive response that provides better protection against acid but creates premalignant tissue with increased risk for adenocarcinoma.
Treatment
- High-dose PPI therapy (twice daily)
- Lifestyle modifications: weight loss, head of bed elevation, avoiding meals before bedtime
- Surveillance endoscopy every 3-5 years for non-dysplastic Barrett's
- Referral for ablation if dysplasia develops