First one with correct answer with justification win.

 

A 10-year old boy who had esophageal atresia repaired as an infant presents with a food bolus impaction at the prior esophageal anastomosis. He has been taking a proton pump inhibitor. At the time of your flexible endoscopy to clear the esophagus you notice a stricture which you dilate. Distal to the stricture you find abnormal, inflamed appearing distal esophageal mucosa. Biopsies of the area identify metaplasia of the intestinal type.

 

 

[size=20px]The next best step in management of his patient with esophageal metaplasia is

 

A adding an H2 blocker.

 

B yearly surveillance endoscopy with biopsy.

 

C radiofrequency ablation.

 

D fundoplication.

 

E esophagectomy.[/size]

(Untitled)

 

B

Think again my dear

D

D

correct

 

Barrett esophagus (BE) is the replacement of the normal stratified squamous epithelium of the esophageal mucosa with metaplastic columnar epithelium that predisposes to cancer development. Metaplastic columnar epithelium can be of three types: gastric fundic, cardia and intestinal. This latter type is known to be associated with an increased risk of adenocarcinoma and most authorities agree that its presence is needed to define BE. Gastroesophageal reflux disease (GERD) is a significant risk factor for BE. GERD is often found in patients following surgical repair of esophageal atresia (EA). It is reported that metaplasia occurs in as many as 15% of EA patients. Due to this risk some authors recommend routine endoscopic surveillance for esophageal atresia patients.

 

One recent publication reviewing the literature on the subject found that of 42 EA patients with BE followed longitudinally with endoscopy, 26 patients still had BE, 17 BE had resolved BE and two had adenocarcinoma. Though rigorous data is lacking it is recommended that children initially be treated aggressively for GERD.

 

For this patient with BE and a stricture while on medical therapy, fundoplication would be the best option. There is no evidence that an additional H2 blocker would prevent progression. Esophagectomy would not be appropriate. Endoscopic surveillance is appropriate long term but inadequate as the next step. Radiofrequency ablation has been used to treat Barrett esophagus in adults although there are case reports of subsequent development of esophageal squamous cell carcinoma and stricture.