Barrett Esophagus and Esophageal Cancer

• Audio chapter
  Single-voice audio, listen on the commute.
• ABIM-format MCQs
  5-option vignettes with full wrong-answer teaching.
• Study guide
  Tables, decision trees, primary sources.
• AI tutor
  Chapter-grounded, answers the question you're stuck on.

What this chapter covers

• Section 4.1: Barrett diagnosis and the Prague C and M criteria

  Barrett esophagus is a metaplastic response of the distal esophagus to chronic acid and bile injury.

• Section 4.2: Pathogenesis, dysplasia progression, and cancer risk

  Barrett esophagus is the price the distal esophagus pays for chronic acid and bile injury, and the cancer risk that follows is graded by dysplasia status.

• Section 4.3: Surveillance intervals and dysplasia management

  Surveillance intervals in Barrett are graded by dysplasia status and segment length, and the algorithm has tightened in the 2022 ACG guideline.

• Section 4.4: Endoscopic eradication therapy (EMR, RFA, ESD, cryotherapy)

  Endoscopic eradication therapy is the modality stack that has replaced esophagectomy for high-grade dysplasia and for most intramucosal cancer in Barrett.

• Section 4.5: Esophageal cancer staging and treatment

  Esophageal cancer has two histologies with different risk factors, locations, and treatment.

Podcast episodes

1. 01

   Barrett Esophagus and Cancer: Without Dysplasia

   This episode follows one fifty-eight-year-old man with long-standing heartburn to show that non-dysplastic Barrett esophagus is a field at risk, not a cancer, and that every decision aims to find dysplasia without over-labeling. It begins with who qualifies for a single screening endoscopy and why those criteria are limited. It then covers the American definition of Barrett, with a view and a biopsy, followed by Prague measurement and Seattle sampling. Next come how Barrett forms and progresses, how his risk sets a one-year then three-year surveillance interval, the role of PPI and aspirin, and when surveillance should stop.

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2. 02

   Barrett Esophagus and Cancer: Dysplasia Treatment

   Barrett esophagus with dysplasia is followed through one patient, a sixty-four-year-old woman whose community biopsy reads high-grade dysplasia. The organizing idea is that every step follows cancer risk and tissue evidence. An expert GI pathologist confirms the reading first, and the grade sets the next step. A slower second endoscopic look comes before treatment because a cancer may be hidden. Anything visible is resected before any ablation, and the depth of the resected lesion decides between endoscopy and surgery. The remaining Barrett is then ablated, usually with radiofrequency ablation, with cryotherapy as salvage. Eradication is not cure, so lifelong twice-daily PPI and intensive early surveillance follow.

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3. 03

   Esophageal Cancer: Staging and Treatment

   Histology comes first, because adenocarcinoma and squamous cell carcinoma differ in cause, location, and treatment before surgery. Two patients with T3 N1 M0 disease carry the episode. The first, a man with distal adenocarcinoma, is taken through risk factors, then staging in a fixed order: endoscopy, CT, PET-CT, and endoscopic ultrasound last. Next come the TNM definitions and what each depth decides, then perioperative FLOT versus chemoradiation, esophagectomy at a high-volume center, and postoperative strictures and reflux. The second patient, with squamous cell carcinoma, shows chemoradiation before surgery, adjuvant nivolumab for residual disease, and definitive chemoradiation without surgery. Metastatic disease and common board traps close the episode.

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Key topics

• ·Screening criteria for Barrett esophagus
• ·Limits of screening and non-endoscopic cell collection
• ·American versus British definition of Barrett
• ·The one-centimeter rule and irregular Z line
• ·Prague classification and Seattle protocol
• ·How Barrett forms and progresses to cancer
• ·Progression risk and tissue biomarkers
• ·Surveillance intervals
• ·PPI, aspirin, and antireflux surgery
• ·When to stop surveillance
• ·Expert GI pathology confirmation
• ·Grades of dysplasia and cancer risk
• ·Indefinite and low-grade dysplasia management
• ·High-grade dysplasia and hidden cancer
• ·Careful second endoscopic look
• ·Resect first, ablate second
• ·Mucosal resection versus submucosal dissection
• ·Depth of invasion and node risk
• ·Radiofrequency ablation and cryotherapy
• ·Complications and surveillance after eradication
• ·Warning pattern of progressive dysphagia
• ·Adenocarcinoma versus squamous cell risk factors
• ·Fixed order of staging tests
• ·Endoscopic resection as staging for early lesions
• ·TNM definitions
• ·Stage-based treatment from T1a to metastatic
• ·Treatment before surgery by histology
• ·Esophagectomy outcomes and postoperative problems
• ·Adjuvant nivolumab and definitive chemoradiation
• ·Metastatic disease and board traps