Brian Fennerty

Reversal of Barrett's esophagus with acid suppression and multipolar electrocoagulation: preliminary results

BACKGROUND Barretts esophagus is a premalignant lesion for esophageal adenocarcinoma. This study tests the hypothesis that re-injury of the metaplastic the epithelium in an acid-controlled environment will result in reversal of Barretts to squamous epithelium. METHODS Patients with at least 2 cm of Barretts esophagus were treated with omeprazole, and half the circumference of the Barretts was treated with multipolar electrocoagulation (MPEC); the other half served as an internal control. After 6 months, the remaining Barretts esophagus was treated with MPEC. RESULTS Twenty-four hour esophageal pH of less than 4 averaged 1.8% on a mean dose of 56 mg/day of omeprazole. Ten patients had visual and biopsy elimination of the targeted section of Barretts esophagus after an average of 2.5 MPEC sessions. The remainder of the Barretts esophagus is being treated in 9 patients; currently 5 have no evidence of Barretts. CONCLUSIONS The combination of control of esophageal acid exposure and reinjury of the metaplastic epithelium reverses Barretts esophagus to squamous epithelium as determined by endoscopy and biopsy.

Barrett's Esophagus on Repeat Endoscopy: Should We Look More Than Once?

BACKGROUND:Barretts esophagus (BE) is the precursor lesion for esophageal adenocarcinoma. The major risk factor for BE is chronic gastroesophageal reflux disease (GERD). Screening patients with longstanding GERD for BE with upper esophagogastroduodenoscopy (EGD) has become the standard practice, and guidelines from national gastrointestinal (GI) societies recommend only a single screening EGD because of limited evidence, suggesting that BE develops early in the course of GERD. We hypothesized that BE may be present in patients in whom initial endoscopy was negative, either due to a missed diagnosis or due to the later development of BE.AIM:The purpose of the study was to determine how often BE is identified on repeat endoscopy performed after an initial negative examination.METHODS:The Clinical Outcomes Research Initiative (CORI) National Endoscopic Database was searched for all patients who had more than one EGD during the 5-yr period between January 1, 2000, and December 31, 2004. Patients who had either procedure for an indication of surveillance of BE were excluded. The primary outcome was a finding of newly suspected BE on repeat examination after an initial negative examination.RESULTS:In total, 24,406 patients underwent more than one endoscopy during the study period. Five hundred sixty-one (2.3%) were found to have suspected BE on repeat EGD following an initial negative examination. More men than women had BE on repeat examination (3.1% vs 1.2%, P < 0.0001). BE on repeat examination was more common in patients with reflux as an indication for endoscopy than in patients with any other indication (5% vs 1.6%, P≤ 0.0001). In reflux patients with esophagitis on initial examination, 9.9% were found to have suspected BE on repeat examination versus 1.8% of reflux patients with no esophagitis on initial examination (P < 0.0001).CONCLUSIONS:BE is rarely found on second endoscopy performed less than 5 yr after an initial negative examination except in patients with esophagitis on the first endoscopy. Repeat EGD for Barretts screening should not be performed out of concern for a missed diagnosis except when BE may have been obscured by overlying esophageal inflammation.

Esophageal ulceration associated with 13-cis-retinoic acid therapy in patients with Barrett's esophagus

Barretts esophagus is a condition in which the normal stratified squamous epithelium of the esophagus is replaced by metaplastic columnar epithelium,I,2 Barretts esophagus is an acquired disorder thought to result from chronic gastroesophageal reflux.,4 It is considered a premalignant lesion for adenocarcinoma of the esophagus,2,5,6 Barretts esophagus is not an uncommon condition with frequency rates of 4 to 16% among patients undergoing endoscopy for reflux. Aggressive medical and surgical efforts to control reflux have not conclusively shown regression of Barretts epithelium or prevention of carcinoma. A novel approach to treatment involves the use of differentiating agents, such as vitamin A analogs, based on their success with other preneoplastic disorders. The well-recognized toxicities of retinoids include central nervous system, skin, skeletal, liver, and lipid abnormalities.9 During a phase II trial of 13-cis-retinoic acid (Accutane; Hoffman-La Roche, Inc.) to evaluate its ability to reverse Barretts mucosa, 2 of 10 patients developed esophageal ulceration. This outcome is being reported to direct attention to this newly recognized complication.

Gallstone pancreatitis: Choosing and timing treatment

Patients with gallstone pancreatitis are often seen initially by primary care physicians. Prompt diagnosis and timely intervention are crucial in reducing morbidity and mortality. Initial management should include supportive medical care and surgical consultation. The timing of surgery is then dictated by serum enzyme levels and liver function test results as well as by the patients condition. The role of endoscopic intervention is currently evolving. Whether surgery or endoscopic sphincterotomy is preferable as primary therapy for gallstone pancreatitis remains unresolved. However, sphincterotomy with stone extraction is a viable option in selected cases, especially in patients who have severe gallstone pancreatitis.