esophagus - nursece4less.comesophagus elizabeth boldon, rn, msn elizabeth boldon is a nurse...

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Barrett’s

Esophagus

Elizabeth Boldon, RN, MSN

Elizabeth Boldon is a Nurse Education Specialist

at Mayo Clinic in Rochester, Minnesota. She received a BSN from Allen College in Waterloo, Iowa in 2002 and an MSN with a

focus in education from the University of Phoenix in 2008. She has bedside nursing experience in medical neurology and the neuroscience ICU.

Abstract

Barrett's esophagus is acquired over time due to severe injury to the

esophageal lining. It may occur as a result of gastroesophageal reflux

disease (GERD) or without the occurrence of GERD. It can exist as a benign

condition or may develop into cancer of the esophagus. Patient survival

depends on correct diagnosis, screening/surveillance and treatment.

Treatment options, such as acid suppression, chemoprevention, ablation

therapy and surgery are discussed.

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Continuing Nursing Education Course Planners

William A. Cook, PhD, Director, Douglas Lawrence, MA, Webmaster,

Susan DePasquale, MSN, FPMHNP-BC, Lead Nurse Planner

Policy Statement

This activity has been planned and implemented in accordance with the

policies of NurseCe4Less.com and the continuing nursing education

requirements of the American Nurses Credentialing Center's Commission on

Accreditation for registered nurses. It is the policy of NurseCe4Less.com to

ensure objectivity, transparency, and best practice in clinical education for

all continuing nursing education (CNE) activities.

Continuing Education Credit Designation

This educational activity is credited for 2 hours. Nurses may only claim credit

commensurate with the credit awarded for completion of this course activity.

Statement of Learning Need

Clinicians need to be able to recognize the symptoms of Barrett’s esophagus

in the adult, and to understand the current trends in the diagnosis of and

treatment of Barrett’s esophagus. Some patients are at risk to develop

Barrett’s esophagus without symptoms, therefore, it is imperative that

patient history and appropriate diagnosis and screening be initiated to avoid

further complications and possible serious outcomes, such as esophageal

cancer.

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Course Purpose

To provide nursing professionals with knowledge to care for patients with

Barrett’s esophagus.

Target Audience

Advanced Practice Registered Nurses and Registered Nurses

(Interdisciplinary Health Team Members, including Vocational Nurses and

Medical Assistants may obtain a Certificate of Completion)

Course Author & Planning Team Conflict of Interest Disclosures

Elizabeth Boldon, RN, MSN, William S. Cook, PhD,

Douglas Lawrence, MA, Susan DePasquale, MSN, FPMHNP-BC –

all have no disclosures

Acknowledgement of Commercial Support

There is no commercial support for this course.

Activity Review Information

Reviewed by Susan DePasquale, MSN, FPMHNP-BC

Release Date: 1/7/2016 Termination Date: 1/7/2019

Please take time to complete a self-assessment of knowledge, on

page 4, sample questions before reading the article.

Opportunity to complete a self-assessment of knowledge learned will be provided at the end of the course.

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1. Barrett's esophagus occurs when squamous cells, which

normally line the lower part of the esophagus, are replaced by

a. intestinal cells.

b. cancer cells.

c. dysplasia.

d. adenocarcinoma cells.

2. Barrett's esophagus usually occurs as a result of repetitive

damage to the inside of the esophagus caused by

a. difficulty swallowing food.

b. a hiatal hernia.

c. gastroesophageal reflux disease (GERD).

d. an esophageal tumor.

3. A typical symptom associated with gastroesophageal reflux

disease (GERD) is

a. a hiatal hernia.

b. peptic stricture.

c. esophageal ulceration.

d. frequent heartburn.

4. Which of the following persons is more likely to have

gastroesophageal reflux disease (GERD)?

a. An African American in his thirties.

b. An Asian male over 50 years old.

c. A male over 50 years old.

d. White male over 50 years old.

5. True or False: Some people diagnosed with Barrett's esophagus

have never experienced heartburn or acid reflux.

a. True

b. False

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Introduction

Barrett’s esophagus is a complication of gastroesophageal reflux disease

(GERD). In Barrett’s esophagus, reflux of gastric contents damage the

normal lining of the lower esophagus, which is then replaced by a different

type of lining (intestinal metaplasia with goblet cells). Patients with Barrett’s

have a 30-125 times increased risk of developing esophageal cancer

compared to the general population. Adenocarcinoma of the esophagus,

which usually arises in a Barrett’s esophagus, has been increasing in

incidence in the United States by 4%-10% per year in recent decades. The

cause of the increase is unknown. Similarly, the role of genetic factors in

Barrett's esophagus and esophagus cancer is not known.2 This course will

discuss this condition, its symptoms, causes, risk factors, diagnosis,

complications and treatment.

What Is Barrett’s Esophagus?

Barrett's esophagus occurs when the normal cells that line the lower part of

the esophagus (squamous cells) are replaced by a different cell type

(intestinal cells). This process usually occurs as a result of repetitive damage

to the inside of the esophagus caused by longstanding acid reflux disease,

called gastroesophageal reflux disease (GERD). In people with GERD, the

esophagus is repeatedly exposed to excessive amounts of stomach acid.

Interestingly, the intestinal cells of Barrett's esophagus are more resistant to

acid than squamous cells, suggesting that these cells may develop to protect

the esophagus from acid exposure. The problem is that the intestinal cells

have a risk of transforming into cancer cells.3

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Barrett's esophagus is most often diagnosed in people who have long-term

gastroesophageal reflux disease (GERD) — a chronic regurgitation of acid

from the stomach into the lower esophagus. Only a small percentage of

people with GERD will develop Barrett's esophagus.

Barrett's esophagus is associated with an increased risk of developing

esophageal cancer. Although the risk is small, it's important for people with

Barrett’s esophagus to have regular checkups for precancerous cells. If

precancerous cells are discovered, they can be treated to prevent

esophageal cancer.

Symptoms

The tissue changes that characterize Barrett's esophagus cause no

symptoms. The signs and symptoms that these patients experience are

generally due to GERD and may include:

Frequent heartburn

Vomiting after eating

Difficulty swallowing food

Less commonly, chest pain

Gastroesophageal reflux disease associated with Barrett's esophagus

frequently is complicated by esophageal ulceration, stricture, and

hemorrhage. In patients with symptomatic GERD, erosive esophagitis is a

risk factor for Barrett's esophagus. Some studies have suggested that

patients with a peptic stricture have a higher prevalence of Barrett's

esophagus than those without strictures.3

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Many people with Barrett's esophagus have no signs or symptoms.

Cause

The exact cause of Barrett's esophagus is not known. Most people with

Barrett's esophagus have long-standing GERD. In GERD, stomach contents

wash back into the esophagus, damaging the esophageal tissue. As the

esophagus tries to heal itself, the cells can change to the type of cells found

in Barrett's esophagus.

However, some people diagnosed with Barrett's esophagus have never

experienced heartburn or acid reflux. It's not clear what causes Barrett's

esophagus in these people.

Risk Factors

Factors that increase the risk of Barrett's esophagus include:

Chronic heartburn and acid reflux

Having GERD for more than five years or having GERD that requires

regular medication and being more than 50 years of age can increase

the risk of Barrett's esophagus. Risk may be further increased for

those thirty years old or younger when chronic GERD develops.

Age

Barrett's esophagus can occur at any age but is more common in older

adults.

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Gender

Men are more likely to develop Barrett's esophagus.

Racial background

Caucasian people have a greater risk of the disease than do people of

other races. It is less common in Hispanic populations, and uncommon

in Asian and black populations.

Being overweight

Body fat around the abdomen further increases risk.

Smoking

Those who smoke cigarettes are at increased risk of Barrett’s

esophagus.

Most people with Barrett's esophagus are in their sixties at the time of

diagnosis. It is thought that most people who are diagnosed with Barrett's

have had it for 10 to 20 years before diagnosis.

Males are three to four times more likely to have Barrett's esophagus

compared to females. Caucasians are about 10 times more likely to have

Barrett's esophagus than African Americans. Although people who

experience weekly heartburn or acid regurgitation are 64 times more likely

to get esophageal adenocarcinoma than people who have never experienced

these symptoms, 40% of people with esophageal adenocarcinoma deny ever

experiencing GERD symptoms. Why these people developed esophageal

adenocarcinoma remains a mystery.1

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Diagnosis Of Barrett’s Esophagus

Upper endoscopy is generally used to diagnose Barrett's esophagus. It is

performed through the placement of a lighted tube with a camera (at the

end of the endoscope) down the throat to check for signs of changing

esophagus tissue. Normal esophagus tissue appears pale and glossy. In

Barrett's esophagus, the tissue appears red and velvety.

The endoscopist is likely to remove a small tissue sample (biopsy). The

biopsy can be examined to determine the degree of tissue change. A

pathologist determines the degree of dysplasia in the esophagus cells. The

tissue may be classified as:

No dysplasia, if Barrett's esophagus is present but no precancerous

changes are found in the cells.

Low-grade dysplasia, if cells show small signs of precancerous

changes.

High-grade dysplasia, if cells show many changes. High-grade

dysplasia is thought to be the final step before cells change into

esophageal cancer.

Complications Of Barrett’s Esophagus

One potential complication of Barrett's esophagus is that, over time, the

abnormal esophageal lining can develop early precancerous changes. The

early changes may progress to advanced precancerous changes, and finally

to frank esophageal cancer. If undetected, this cancer can spread and invade

surrounding tissues.

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Progression to cancer is uncommon. Studies that follow patients with

Barrett's esophagus reveal that less than 0.5 percent of patients develop

esophageal cancer per year. Furthermore, patients with Barrett's esophagus

appear to live approximately as long as people who are free of this

condition. Patients often die of other causes before Barrett's esophagus

progresses to cancer.3

Treatment of Barrett’s Esophagus

Treatment for Barrett's esophagus depends on the degree of dysplasia found

in the esophagus cells and the patient’s overall health. Dysplasia is a

precancerous condition that doctors can only diagnose by examining tissue

samples under a microscope. When dysplasia is seen in the tissue sample, it

is usually described as being “high-grade,” “low-grade” or “indefinite for

dysplasia.”

In high-grade dysplasia, abnormal changes are seen in many of the cells and

there is an abnormal growth pattern of the cells. Low-grade dysplasia means

that there are some abnormal changes seen in the tissue sample but the

changes do not involve most of the cells, and the growth pattern of the cells

is still normal. “Indefinite for dysplasia” simply means that the pathologist is

not certain whether changes seen in the tissue are caused by dysplasia.

Other conditions, such as inflammation or swelling of the esophageal lining,

can make cells appear dysplastic when they may not be.2

It is advisable to have any diagnosis of dysplasia confirmed by two different

pathologists to ensure that this condition is present in the biopsy.

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Reducing or getting rid of a person’s acid reflux often is the first line of

treatment for Barrett’s esophagus. Treatment does not usually cure the

Barrett's esophagus, but it keeps it from worsening.

The medical provider will likely prescribe medication to decrease stomach

acid. He or she might also recommend that the patient do the following:

Avoid caffeine drinks, alcohol, chocolate, peppermint, and fatty foods.

These foods can make acid reflux worse. Acidic juices such as orange

or tomato juice may also worsen symptoms. Carbonated beverages

can also be a problem for some people.

Avoid eating before going to bed, eating large meals, or lying down

after eating.

Raise the head of bed by six to eight inches.

No Dysplasia or Low-grade Dysplasia

Periodic endoscopy is performed to monitor the cells in the esophagus. If

biopsies show no dysplasia, follow-up will likely include an endoscopy in one

year and then every three years if no changes occur. If low-grade dysplasia

is found, the provider may recommend another endoscopy in six months or

a year. (More about monitoring is listed in the text box below).

Gastroesophageal Reflux Disease

Medication and lifestyle changes can ease the signs and symptoms of

gastroesophageal reflux disease (GERD). Surgery to tighten the sphincter

that controls the flow of stomach acid may be an option. Treating GERD

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doesn't treat the underlying Barrett's esophagus but can help make it easier

to detect dysplasia.

A clinician may prescribe medications that reduce the amount of acid

produced by the stomach. A class of medications called proton pump

inhibitors (PPIs) is commonly recommended. Five different formulations

(some of which are available as a generic) are currently available:

omeprazole (Prilosec), esomeprazole (Nexium), lansoprazole (Prevacid),

rabeprazole (Aciphex) and pantoprazole (Protonix).

There is data to suggest that aspirin and other nonsteroidal anti-

inflammatory drugs (NSAIDs) that inhibit cyclooxygenase (COX) may protect

against the development of Barrett's esophagus, or protect against the

development of cancer in patients with established Barrett's esophagus.

However, given the potential for adverse effects and the overall low absolute

risk of developing esophageal adenocarcinoma, it is not routinely

recommended for patients with Barrett's esophagus to take NSAIDs solely

for the purpose of chemoprevention.

Studies that have examined the efficacy of chemoprevention in patients with

Barrett's esophagus have found that the use of aspirin or NSAIDs reduces

the risk of esophageal adenocarcinoma by approximately 40 percent. The

protective effect may be greater if the NSAID is combined with a statin.

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A large trial evaluating the efficacy and safety of aspirin for the prevention of

cancer in Barrett's esophagus (the ASPECT trial) is being conducted in the

United Kingdom.4

Monitoring for precancerous changes is recommended for most patients with Barrett's

esophagus. At this time, monitoring includes periodic endoscopy with tissue biopsy.

Although new technologies for monitoring are on the horizon, most are still considered to

be experimental. Experts do not agree about the usefulness of monitoring. The benefits of

monitoring depend upon each person's chance of developing esophageal cancer, which may be difficult to determine.4

Benefits — Reasons to perform endoscopic monitoring include:

Monitoring can detect precancerous changes (dysplasia) in the esophageal lining. These changes may indicate that the person has an increased risk of cancer. Early

detection may be especially important for younger patients.

Monitoring may detect cancer at an earlier stage, when it can be more effectively treated.

Limitations — Not all patients will benefit from endoscopic monitoring.

Progression of Barrett's esophagus to cancer is uncommon. Endoscopy carries certain risks and often causes anxiety.

Endoscopy may miss areas with premalignant changes or cancer.

Even if endoscopy detects cancer, the available treatment options may have unacceptably high risks.

High-grade Dysplasia

A person with high-grade dysplasia has more limited options. The

management of this condition is controversial. The optimal treatment

depends upon the person's age and health and the patient and physician's

preference. The options include removal of the esophagus (esophagectomy)

and removing or destroying the abnormal tissue using endoscopic

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techniques. Removal of abnormal tissue involves, i.e., endoscopic mucosal

resection. Destruction of abnormal tissue involves, i.e., radiofrequency

ablation, photodynamic or other ablation therapies.4

Esophagectomy

In removing the esophagus, esophagectomy removes all of the precancerous

tissue and some of the lymph nodes near the esophagus. However, this

treatment has higher rates of procedure-related death and long-term

complications than the endoscopic treatments for dysplasia.

Esophagectomy is not necessary in most patients who have dysplasia in

Barrett’s esophagus. In some patients, however, it may not be possible to

destroy all of the abnormal tissue by endoscopic treatments, and

esophagectomy may be recommended for those patients. An experienced

physician in a hospital where esophagectomy is done frequently should

perform the procedure. In one study of 340 esophagectomies performed at

25 different hospitals, the mortality rate was three percent for patients who

had the operation at institutions that did five or more esophagectomies per

year, compared to 12 percent for patients treated at institutions where the

operation was performed less frequently.4,5,6

Endoscopic mucosal resection

Endoscopic mucosal resection (EMR) involves the removal of a large but thin

area of esophageal tissue through an endoscope. EMR provides large tissue

specimens that can be examined by the pathologist to determine the

character and extent of the abnormality and determine if an adequate

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amount of tissue was removed. Therefore, it can help to confirm the

person's diagnosis and completely treat the abnormality (if the abnormal

tissue is removed completely). However, this technique is generally

performed only in specialized centers. Generally, EMR is performed if the

endoscopist sees an area of nodularity in the Barrett’s esophagus. EMR is

commonly followed by ablation of the remaining Barrett’s esophagus, usually

with radiofrequency ablation (discussed below).4,5,6

An understanding of the efficacy of endoscopic resection for management of

high-grade dysplasia or early cancer in Barrett's esophagus is evolving. The

available evidence suggests that endoscopic resection for these conditions

has an initial success rate comparable to surgical treatment, but with fewer

complications.

The rate of complete remission (i.e., successful removal of the high-grade

dysplasia or early cancer) is variable, ranging from 59 to 99 percent in

different studies. In a systematic review that included 11 studies of patients

with Barrett’s esophagus who underwent endoscopic mucosal resection,

complete remission was achieved in 95 percent of patients, and complete

eradication of all Barrett's mucosa was achieved in 89 percent.

Recurrence of carcinoma or the development of other related malignancies

has been described in 6 to 30 percent of patients. Multiple factors have been

associated with recurrence, such as:

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Larger lesion diameter

Removal of the lesion with piecemeal resection

Failure to perform adjunctive ablative therapy (photodynamic therapy,

argon plasma coagulation, or radiofrequency ablation)

Presence of multiple lesions

An elapsed time of more than 10 months prior to achieving complete

remission

The presence of residual dysplasia

In most cases, recurrences can be successfully managed endoscopically.4,5,6

Radiofrequency ablation

Radiofrequency ablation (RFA) is an endoscopic procedure that uses

radiofrequency energy (microwaves) to destroy the Barrett’s cells. In short-

term studies, RFA has been shown to prevent high-grade dysplasia from

progressing to cancer and to prevent low-grade dysplasia from developing

more advanced features. However, there is limited information on the long-

term outcome of this approach. In up to five percent of patients, the

procedure causes a complication, such as narrowing of the esophagus, which

may require repeated treatments to open the esophagus.4,5

Another concern with RFA is that, in a small minority of patients with high-

grade dysplasia (less than two percent), there may be cancer in the lymph

nodes adjacent to the esophagus. RFA cannot cure cancer in the lymph

nodes. In all cases, the patient and family should discuss the risks and

benefits of possible treatments with a healthcare provider.4

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Photodynamic therapy

Photodynamic therapy is a treatment that uses chemical agents, known as

photosensitizers, to kill certain types of cells (such as Barrett's cells) when

the cells are exposed to laser light. Patients are given the photosensitizer

medication into a vein and then undergo endoscopy. During the endoscopy,

a laser light is used to activate the photosensitizer and destroy the Barrett's

tissue.

However, there is limited information on the long-term outcome of this

approach. Furthermore, photodynamic therapy is expensive and available in

only a small number of academic medical centers. In up to 40 percent of

patients, the procedure causes a complication, such as narrowing of the

esophagus, which may require repeated treatments to open the esophagus.

Another concern with photodynamic therapy is that patients with high-grade

dysplasia may have areas of invasive cancer that are not treated adequately.

Photodynamic therapy has largely been replaced by RFA, which appears to

be safer and at least as effective. In all cases, the patient and family should

discuss the risks and benefits of possible treatments with a healthcare

provider.4,5

Endoscopic spray cryotherapy

Endoscopic spray cryotherapy is a newer technique for ablation of Barrett's

mucosa. A cryotherapy system is used to apply cold nitrogen or carbon

dioxide gas endoscopically to the Barrett's esophagus. The tissue is frozen

for approximately 40 seconds (two 20-second applications or four 10-second

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applications). Observational studies suggest that it eradicates high-grade

dysplasia in approximately 95 to 100 percent of patients, all dysplasia in 85

to 90 percent, and all intestinal metaplasia in 55 percent. However, very

little long-term data are available, and RFA remains the most commonly

used ablation technique at this time.4,5,6

Screening For Barrett’s Esophagus

To decrease mortality from esophageal adenocarcinoma, it has been

proposed that patients with gastroesophageal reflux disease (GERD)

symptoms should be screened endoscopically for Barrett's esophagus. The

American Gastroenterological Association guideline recommends against

screening the general population of patients with GERD for Barrett's

esophagus, and instead recommends screening only for patients with

multiple risk factors for adenocarcinoma including chronic GERD, hiatal

hernia, age ≥50, male gender, white race, elevated body mass index, and

intra-abdominal body fat distribution.4,5

It is not clear that screening patients with GERD symptoms reliably identifies

individuals at high risk for esophageal adenocarcinoma or has an impact on

mortality. Long-segment Barrett's esophagus can be found in 3 to 5 percent

of patients who have endoscopy for chronic GERD symptoms, whereas 10 to

15 percent have short-segment Barrett's esophagus. Studies have also

shown that patients with GERD symptoms are at increased risk for

esophageal adenocarcinoma.4,5

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Another limitation of screening patients with GERD symptoms for Barrett's

esophagus and esophageal adenocarcinoma is that more than 40 percent of

patients with esophageal adenocarcinoma have no history of heartburn.

Thus, any screening program that targets only patients with heartburn can

have only limited impact on cancer mortality rates and there is little

evidence that these programs have prevented deaths from esophageal

adenocarcinoma. In published series of patients found to have these tumors,

fewer than five percent were known to have had Barrett's esophagus before

they presented with symptoms of esophageal cancer.3,4 It is also not clear

whether patients who are known to have Barrett's esophagus benefit from

surveillance and, once the diagnosis of Barrett's esophagus has been

established, patients are subject to worry about the diagnosis and the

inconvenience and risk associated with surveillance, as well as worry about

the potential financial burden from an increase in life insurance premiums.4,5

Summary

Barrett’s esophagus is a condition in which the lining of the esophagus

changes, becoming more like the lining of the small intestine rather than the

esophagus. This occurs in the area where the esophagus is joined to the

stomach. It is believed that the main reason that Barrett’s esophagus

develops is because of chronic inflammation.

Barrett’s esophagus is more common in people who have had GERD for a

long period of time or who developed it at a young age. It is interesting that

the frequency or the intensity of GERD symptoms, such as heartburn, does

not affect the likelihood that someone will develop Barrett’s esophagus.

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Most patients with Barrett’s esophagus will not develop cancer. In some

patients, however, a precancerous change in the tissue, called dysplasia, will

develop. That precancerous change is more likely to develop into esophageal

cancer.

At the current time, a diagnosis of Barrett’s esophagus can only be made

using endoscopy and detecting a change in the lining of the esophagus that

can be confirmed by a biopsy of the tissue. The definitive diagnosis of

Barrett’s esophagus requires biopsy confirmation of the change in the lining

of the esophagus.

Despite the uncertainties surrounding the monitoring and treatment of

Barrett's esophagus, there is consensus on one matter: the available options

should be tailored to the individual patient. Clinicians need to understand

and pursue general guidelines for the treatment of Barrett’s esophagus,

specifically:

People with Barrett's esophagus should be treated to decrease reflux

symptoms. This may improve or eliminate symptoms of heartburn,

reduce inflammation, help prevent complications, and improve the

accuracy of endoscopy results.

People without evidence of precancerous changes (i.e., no dysplasia)

or esophageal cancer should have endoscopy performed every three to

five years to look for the development of precancerous changes, unless

there are other medical conditions that increase the small risks usually

associated with endoscopy.

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If endoscopy reveals a precancerous change (dysplasia); this finding

should be confirmed by at least one expert; if necessary, additional

tissue samples should be collected to resolve any doubt.

People with early precancerous changes (low-grade dysplasia) often

are advised to have repeat endoscopy at six and 12 months, followed

by annual endoscopy if the lesion does not appear to progress. In

some cases, RFA may be considered to treat low-grade dysplasia.

People with advanced precancerous changes (high-grade dysplasia)

should have their diagnosis confirmed by an expert. If the diagnosis is

confirmed, treatment usually involves a combination of EMR and RFA.

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of Knowledge Questions after reading the article, and providing

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1. Barrett's esophagus occurs when squamous cells, which

normally line the lower part of the esophagus, are replaced by

a. intestinal cells.

b. cancer cells.

c. dysplasia.

d. adenocarcinoma cells.

2. Barrett's esophagus usually occurs as a result of repetitive

damage to the inside of the esophagus caused by

a. difficulty swallowing food.

b. a hiatal hernia.

c. gastroesophageal reflux disease (GERD).

d. an esophageal tumor.

3. A typical symptom associated with gastroesophageal reflux

disease (GERD) is

a. a hiatal hernia.

b. peptic stricture.

c. esophageal ulceration.

d. frequent heartburn.

4. Which of the following persons is more likely to have

gastroesophageal reflux disease (GERD)?

a. An African American in his thirties.

b. An Asian male over 50 years old.

c. A male over 50 years old.

d. White male over 50 years old.

5. True or False: Some people diagnosed with Barrett's esophagus

have never experienced heartburn or acid reflux.

a. True

b. False

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6. The intestinal cells of Barrett's esophagus

a. are less resistant to acid than the normal, squamous cells.

b. make swallowing food more difficult.

c. are at risk of transforming into cancer cells.

d. create body fat around the abdomen.

7. Which of the following is generally used to diagnose Barrett's

esophagus?

a. A biopsy

b. Upper endoscopy

c. Microscopic examination of tissue samples

d. Radiofrequency ablation (RFA)

8. High-grade dysplasia is determined by a pathologist if

a. cells show many signs of precancerous changes.

b. Barrett's esophagus is present but no precancerous cells.

c. cells show small signs of precancerous changes.

d. esophageal cancer is present.

9. A patient diagnosed with dysplasia should

a. avoid eating first thing in the morning.

b. have the diagnosis confirmed by a second pathologist.

c. be immediately tested for peptic stricture.

d. eat one large meal instead of multiple, smaller meals.

10. If a patient shows no dysplasia or low-grade dysplasia, the

patient should

a. follow-up with an endoscopy every six months.

b. follow-up with an endoscopy in one year, then every three years if

no changes.

c. take nonsteroidal anti-inflammatory drugs (NSAIDs) for

chemoprevention.

d. rely on lifestyle changes unless changes occur.

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11. A healthcare provider should recommend that a patient with

Barrett's esophagus do the following:

a. Avoid caffeine drinks, alcohol, chocolate, peppermint, and fatty

foods.

b. Avoid eating before going to bed.

c. Raise the head of his or her bed by six to eight inches.

d. All of the above.

12. For persons with Barrett's esophagus, if biopsies show no

dysplasia, the patient should

a. have an endoscopy every six months.

b. have an endoscopy in one year, then every 3 years if no changes.

c. rely on lifestyle changes unless symptoms arise.

d. take nonsteroidal anti-inflammatory drugs (NSAIDs) to prevent

dysplasia.

13. A person diagnosed with high-grade dysplasia should first

a. try endoscopic treatments to remove all abnormal tissue.

b. have an esophagectomy to remove all of the precancerous tissue.

c. have lymph nodes near the esophagus removed.

d. have an Endoscopic mucosal resection (EMR).

14. ___________________________ involves the removal of a

large but thin area of esophageal tissue through an endoscope.

a. A biopsy

b. A radiofrequency ablation (RFA)

c. An esophagectomy

d. An endoscopic mucosal resection (EMR)

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15. _________________________ is a treatment that uses

chemical agents, known as photosensitizers, to kill certain types

of cells (such as Barrett's cells).

a. Radiofrequency ablation (RFA)

b. Photodynamic therapy

c. Endoscopic mucosal resection (EMR)

d. Endoscopic spray cryotherapy

16. A newer technique for ablation of Barrett's mucosa is

a. endoscopic mucosal resection.

b. the use of nonsteroidal anti-inflammatory drugs (NSAIDs).

c. photodynamic therapy.

d. endoscopic spray cryotherapy.

17. A limitation of screening patients with GERD symptoms for

Barrett's esophagus and esophageal adenocarcinoma is

a. GERD patients have different symptoms than Barrett’s esophagus.

b. Many people with Barrett's esophagus have no signs or symptoms.

c. more than 40% of esophageal adenocarcinoma patients had no

history of heartburn.

d. patients often die of other causes before Barrett's esophagus

progresses to cancer.

18. Esophageal adenocarcinoma is defined as

a. cancer of the squamous cells.

b. low-grade dysplasia

c. esophageal cancer

d. high-grade dysplasia

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19. Radiofrequency ablation (RFA)

a. causes narrowing of the esophagus in some patients.

b. also treats cancer in the lymph nodes near the esophagus.

c. is only effective to treat low-grade dysplasia.

d. is used only when advanced, esophageal adenocarcinoma is present.

20. True or False: Esophagectomy should be performed by an

experienced physician in a hospital where the procedure is

performed frequently.

a. True

b. False

CORRECT ANSWERS:

1. a

2. c

3. d

4. d

5. a

6. c

7. b

8. a

9. b

10. b

11. d

12. b

13. a

14. d

15. b

16. d

17. c

18. c

19. a

20. a

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References Section

The reference section of in-text citations include published works intended as

helpful material for further reading. Unpublished works and personal

communications are not included in this section, although may appear within

the study text.

1. Barrett’s Esophagus. (2006) American College of Gastroenterology.

Retrieved December 28, 2015 from www.patients.gi.org

2. Barrett’s esophagus. (2014) Mayo Foundation for Medical Education and

Research. Retrieved October 10, 2015 from www.mayoclinic.org

3. Spechler, S.J. (2015) Barrett’s esophagus: Epidemiology, clinical

manifestations, and diagnosis in Talley, N.J. (Ed.), UpToDate. Waltham,

Mass.: UpToDate. Retrieved December 20, 2015 from

www.uptodate.com

4. Spechler, S.J. (2015) Barrett’s esophagus: Surveillance and

management in Talley, N.J. (Ed.), UpToDate. Waltham, Mass.:

UpToDate. Retrieved December 20, 2015 from www.uptodate.com

5. Spechler SJ, Sharma P, Souza RF, et al. American Gastroenterological

Association technical review on the management of Barrett's

esophagus. Gastroenterology 2011; 140:e18.

6. Teran MD, Brock MV. The management of Barrett's esophagus. In:

Cameron, JL, Cameron AM, eds. Current Surgical Therapy. 11th ed.

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http://www.patients.gi.org/

http://www.mayoclinic.org/

http://www.uptodate.com/

http://www.uptodate.com/

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