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Gastroenterology and Hepatology Board Review for November 2022 Board examination

 

  1. Barrett’s with high grade dysplasia (HGD)

  • Biopsies q 1 cm all 4 quadrant

  • Endoscopic mucosal resection (EMR) of any nodularity

  • Rate of progression to cancer is 6% per year


  1.  Barrett’s with low grade dysplasia (LGD)

  • Confirm with an expert pathologist and repeat EGD with biopsy in 6 months. If still LGD then repeat EGD in 1 year

  • PPI once a day in the absence of esophagitis

  • Rate of progression to HGD or cancer is 0.5-13% per year


  1. Barrett’s esophagus - tongue of salmon colored mucosa noted

  • Intestinal metaplasia of GE junction- no tongue of abnormal mucosa present


  1. Barrett’s with indefinite dysplasia, optimize therapy and repeat EGD in 3-6 months


  1. Once complete eradication of intestinal metaplasia (CEIM) is accomplished via radiofrequency ablation (RFA) therapy

  • Repeat EGD q3 months x 1 year 

  • Followed by q6 months for another year 

  • Followed by q1 year from then on


  1. Patient with Barrett’s on twice daily dose proton pump inhibitors (PPI) and ongoing symptoms

  • Check pH impedance while ON medications to evaluate for fundoplication


  1. Barrett’s unresponsive to RFA (HALO), optimize acid suppression therapy with PPI


  1. Barrett’s recurrence after treatment is most common at Gastroesophageal (GE) junction 


  1. Screening for Barrett’s 

  • Patients with frequent gastroesophageal reflux disease (GERD) symptoms for 5-10 years and 2 or more following risk factors

  • Caucasian male

  • Central obesity

  • Age> 50(e.g.-Screening for Barrett’s in white males > 50 years)

  • Smoker

  • Family history of Barrett’s or esophageal cancer

  • No survival benefits demonstrated with screening or surveillance

  • Screening and surveillance in patients with Barrett’s esophagus with dysplasia may be cost effective (without dysplasia- cost prohibitive)

  • 10% of chronic GERD have Barrett’s, 50% of Barrett’s have no GERD symptoms


  1. WATS-3D and Seattle protocol biopsy sampling compares well with white-light endoscopy with Seattle protocol biopsy sampling in patients with Barrett’s (ASGE 2019)


  1. Any esophageal cancers (or rectal cancers) > T2 or N0 need neoadjuvant therapy

  • Eg1- Esophageal ca T1N1- refer to neoadjuvant therapy.

  • Eg2- Esophageal adenocarcinoma T3N0 treated by neoadjuvant therapy + surgery

  • Management of esophageal T1 lesions is EMR. No bronchoscopy needed in esophageal cancer below carina


  1. Elderly patient with esophagogastric junction outlet obstruction with weight loss, EUS needed to r/o mass

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