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Update in Gastroenterology
- Ronald L. Koretz, MD
- From Olive View–University of California, Los Angeles, Medical Center, Sylmar, California.
2003-2004 Series: Update Sessions from ACP's 2003 Annual Session
This Update reviews several important papers from the gastroenterology literature published during 2002. My recommendations reflect both the best available evidence and today's cost-constrained practice environments. The papers are grouped into four categories: Barrett esophagus, Helicobacter pylori, hepatology, and inflammatory bowel disease.
Barrett Esophagus
I will consider the literature on screening or surveillance for Barrett esophagus. In programs designed to screen for Barrett esophagus, members of the general population who are believed to be at increased risk (usually those with gastroesophageal reflux, although, as we will see, the at-risk population may be larger) undergo endoscopic evaluation once to establish or exclude the disease. Surveillance programs are used only in patients with Barrett esophagus; these programs require periodic endoscopic evaluations, including biopsies, to look for dysplasia or early adenocarcinoma.
Surveillance for Barrett Esophagus Appears To Be Associated with Better Outcomes in Esophageal Cancer, but a Randomized, Controlled Trial Is Needed
The authors of this paper, from the Northern California Kaiser Permanente group, compared the long-term outcomes of esophageal cancer in patients with Barrett esophagus who had undergone surveillance and those who had not. Five hundred eighty-nine patients had adenocarcinoma of the esophagus or gastric cardia, but only 135 (23%) had documented Barrett esophagus. Furthermore, only 23 of these 135 (17%) had received a diagnosis of Barrett esophagus more than 6 months before cancer was discovered. In the remaining patients, the diagnosis of Barrett esophagus was first established when the tumor was resected.
Of the 23 patients with previously diagnosed Barrett esophagus, 15 received a diagnosis of esophageal cancer during a surveillance procedure. These 15 patients had less advanced cancer than those whose cancer was discovered by other means. Survival was much better in the surveillance patients. Eleven (73%) were alive at the end of follow-up (mean, 6.1 years) compared with none of the 8 patients who had cancer diagnosed after symptom development (P = …
