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.
- This patient most likely has:
a. Metastatic testicular carcinoma
b. Esophageal cancer
c. Pernicious anemia
d. Gastric neoplasia
e. Barrett’s esophagus
- 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.