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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.
Please take time to help NurseCe4Less.com course planners evaluate
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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.
Philadelphia, PA: Elsevier Saunders; 2014: chap 4.
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