A case of dysplastic Barrett's

August 05, 2011 By: Bjorn Rembacken

This shows the distal oesophagus of a 65 year old man on a Barrett's surveillance programme. He is entirely asymptomatic, although samples taken 12 and 6 month earlier had found high-grade dysplasia within the Barrett's. He has now been referred for a second opinion. His oesophagus is examined with high-definition, narrow band imaging, indigo carmine dye spray and autofluorescence.

What is the correct management?
a) Take another round of samples
b) Remove the unstable areas identified with the trimodality imaging
c) Ablate the Barrett's using photodynamic imaging
d) Ablate the Barrett's using radiofrequency ablation
e) Refer the patient for an oesophagectomy


Even with white light you can see that the mucosa is nodular.  This is the appearance of dysplastic Barrett’s, remarkable similar to the appearance of dysplastic ulcerative colitis.  The indigo-carmine image emphasizes this further.  Towards the end of the video clip you see the auto-fluoroscopic images.  It takes some getting used to and the technology is plagued by a lot of false positives.  Nevertheless, the video indicate that there are multiple areas of unstable Barrett's (pink patches). 

However, a more important issue than all of this is the area of stricturing.  The presence of a stricture is suspicious for invasive Barrett's cancer.  Even if the strictured area only contains high-grade dysplasia, it would be difficult to treat endoscopically at the stiff ablation catheters will not be able to treat the sharp angulation.  For these reasons, the correct answer is E - refer for surgical resection!  Analysis of the resected oesophagus confirmed an invasive cancer (sm2 invasion) but all lymphnodes were negati ve for cancer.

I have reservations about our ability to accurately identify pathes of Barrett's dysplasia by endoscopic means.  On careful reading of most studies, you will conclude that random biopsies are still needed.  Taking "mapped samples" whereby you carefully record the level   (in cm from the mouth) and the laterial location (in a clock face fashion) is a good way to confirm precisely where the dysplasia is located.  Naturally, if there is a small, visible nodule, this would not be needed.

About the author

Bjorn Rembacken is at Leeds Teaching Hospitals NHS Trust, Leeds, UK. He was born in Sweden and qualified from Leicester University in 1987. He undertook his postgraduate education in Leicester and in Leeds. His MD was dedicated to inflammatory bowel disease. Dr Rembacken was appointed Consultant Gastroenterologist, Honorary Lecturer at Leeds University and Endoscopy Training Lead in 2005. Follow Bjorn on Twitter @Bjorn_Rembacken

 

Comments

Nazish, October 24, 2015 09:10
Esophagectomy

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