Gastrointestinal · Year 2 · from Gastrointestinal
Case 1: Gastroesophageal Reflux Disease with Barrett's Esophagus
Patient Presentation
Demographics: 62-year-old male
Chief Complaint: Chronic heartburn for 20 years with recent worsening dysphagia
History of Present Illness: The patient has experienced heartburn and regurgitation for over two decades, managed with intermittent over-the-counter antacids and PPIs. Over the past 6 months, he has noticed solid foods "sticking" in his lower chest, requiring multiple sips of water to pass. He has lost 8 pounds unintentionally. He denies odynophagia or hematemesis.
Past Medical History: Obesity (BMI 32), hypertension, hyperlipidemia
Social History: 25 pack-year smoking history (quit 10 years ago), occasional alcohol use
Physical Examination
- Vital Signs: BP 142/88 mmHg, HR 76 bpm
- General: Obese male in no acute distress
- Abdomen: Soft, obese, non-tender
- Cardiac/Pulmonary: Unremarkable
Workup and Results
- Upper Endoscopy: Long-segment Barrett's esophagus (8 cm) with a nodular area; distal esophageal stricture at 36 cm
- Histopathology: Intestinal metaplasia with goblet cells; nodular area shows high-grade dysplasia
- CT Chest/Abdomen: No lymphadenopathy or metastatic disease
Endoscopic image showing Barrett's esophagus with salmon-colored columnar mucosa extending above the gastroesophageal junction. The irregular nodular area (arrow) was found to harbor high-grade dysplasia on biopsy.
Image Source: Wikimedia Commons, CC BY-SA 4.0
Diagnosis
Barrett's Esophagus with High-Grade Dysplasia and Peptic Stricture
Clinical Correlation
Barrett's esophagus represents intestinal metaplasia in response to chronic acid exposure. The progression from non-dysplastic Barrett's to low-grade dysplasia, high-grade dysplasia, and invasive adenocarcinoma follows a predictable sequence. High-grade dysplasia carries 5-10% annual progression risk to cancer and requires treatment. The peptic stricture developed from chronic inflammation and fibrosis, explaining the dysphagia to solids.
Treatment
- Endoscopic eradication therapy: radiofrequency ablation (RFA) for flat dysplasia combined with endoscopic mucosal resection (EMR) for the nodular component
- Stricture dilation at time of endoscopy
- Continued high-dose PPI therapy indefinitely
- Surveillance endoscopy every 3 months after treatment until eradication confirmed