Question of the Day... Barrett's Oesophagus

This question was taken from the Glasgow Oct 2013 Exam. It was a communications skills station, however some basic knowledge is still required.

Question:
Mr. Brown has had a Barium swallow that shows a stricture. Please counsel him for OGD and dilatation.

Answer:
Risk factors for oesophageal cancer:

• Age - >60
• Gender - Males > Females
• Smoking and heavy alcohol use - use together increases risk more than either individually.
• GORD - Gastro-Oesophageal Reflux Disease and Barretts Oesophagus
• Obesity
• Previous Radiation
• Family History of Oesophageal Ca

Clinical Evaluation

• Gold standard - OGD
• Imaging - Barium swallow/barium meal

Biopsies taken during OGD are then examined histologically for signs of malignancy.

Staging scans:

• CT Thorax/Abdomen/Pelvis - to determine distal metastases, espcially LN and liver
• EUS - provides T staging

Location of the tumour determined by distance from incisors.

Red flags

• Dysphagia
• Anorexia/early satiety
• Jaundice
• Persistent projectile vomiting
• Palpable Abdominal Mass
• Unexplained weight loss >10% body weight or 3kg
• Anaemia
• PR bleeding/Melaena/Haematemesis

Barrett's Oesophagus

Definition = metaplasia of lower oesophageal epithelium from normal stratified squamous epithelium to simple columnar epithelium with Goblet cells.

• Strong association with adenocarcinoma
• Diagnosis of Barrett's requires histological confirmation of the presence of Goblet cells (Specialize Intestinal Metaplasia or SIM)

Pathophysiology

GORD causes chronic inflammation that causes damage to the cells of the gastro-oesophageal junction.

Epidermal Growth Factor Receptor inhibited by bile acids causes intestinal differentiation.

Biopsy Protocol

The Seattle Biopsy protocol requires 4 quadrant biopsies every 2 cm with targetted biopsies on macroscopically visible lesions. Distal biopsies taken 1st starting 1-2 cm above GOJ and advancing proximally to minimise obscured view from bleeding.