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Diagnostic Dilemma

Diagnostic Dilemma

A 60-year-old attorney presents with chronic heartburn and regurgitation.
His symptoms have steadily increased over the last 2 years, and he is currently
using daily therapy with a proton pump inhibitor. There is no history of
gastrointestinal bleeding, dysphagia, or weight loss.

His medical history is positive for chronic lung disease, marked
kyphoscoliosis, hypertension, and testicular cancer when he was an adolescent.
Family history is positive for chronic gastroesophageal reflux and Barrett’s
esophagus in his mother and colonic carcinoma in his father.

Colonoscopy
revealed diverticulosis and two small adenomatous polyps that
were removed. Upper gastrointestinal endoscopy revealed a 3-cm hiatal hernia,
10 cm of columnar lining in the body of the esophagus, and multiple polyps in
the stomach. The endoscopic photograph (right) demonstrates the largest polyp, which is
located on the posterior wall of the antrum. There is a smaller polyp just
distal to this polyp. There were several smaller polyps in the gastric body and
fundus.

  1. This patient most likely has:
    a. Metastatic testicular carcinoma
    b. Esophageal cancer
    c. Pernicious anemia
    d. Gastric neoplasia
    e. Barrett’s esophagus
  2. The appropriate management includes:
    a. Surgical resection of the antrum
    b. Laparoscopic fundoplication
    c. Multiple biopsies of the esophagus
    and polyps
    d. Laser therapy of the esophagus
    e. Antibiotic treatment for Helicobacter
    pylori

The correct answers to question 1 are d and e. The photograph reveals a large, friable
polyp in the distal portion of the stomach. Polyps of this size (2 cm) and
appearance are usually neoplastic. Smaller polyps are usually non-neoplastic,
ie, hyperplastic or fundic gland type.

The endoscopic finding of a long segment of columnar lining in the body of
the esophagus is consistent with Barrett’s esophagus. This is a premalignant
condition that is associated with chronic acid reflux. The endoscopic exam did
not show any evidence of esophageal cancer. Likewise, the endoscopic
examination did not show evidence of gastric atrophy, which would be present
along with achlorhydria in a patient with pernicious anemia. The patient’s
history of testicular cancer is remote, making metastatic disease unlikely.

The correct answer to question 2 is c. To confirm the diagnosis of Barrett’s
esophagus, biopsies must be performed, and evidence of specialized intestinal
metaplasia should be documented histologically in the body of the esophagus. In
addition, multiple biopsies are required to assess for dysplasia.

Biopsies of the polyps are also indicated. If adenomatous changes are
present and there is no evidence of carcinoma, attempts at endoscopic therapy
are warranted in this patient with multiple medical problems. Surgical
resection for the polyps and fundoplication for acid reflux and Barrett’s
esophagus are premature considerations at this point.

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