Follow Up: Barrett's Oesophagus

Casebank Counselling
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Candidate instructions

Where you are:
You are FY2 in the outpatient department.

Who the patient is:
Peter Smith, 52-year-old man who had an Endoscopy with biopsy done. The patient has a past history of GERD and is on omeprazole 20 mg daily.

Other information you have about your patient:
A copy of the biopsy results from the histopathology department is available in the cubicle.

What you must do:
Talk to the patient, explain the results and discuss management with the patient.

Patient information

  • You are 52 years old.
  • You had GERD for years.
  • Your symptoms are getting worse.
  • The symptoms are not being controlled by Omeprazole anymore, that’s why you had Endoscopy done.
  • You have night symptoms which wakes you up from sleep.
  • You smoke 20 cigarettes per day for 20 years
  • You drink a lot of alcohol
  • Your diet is poor
  • You work as a pizza delivery man.

Questions

  1. Why can’t you cut it out?
  2. Why can’t you just do Endoscopy now?

Examiner’s prompt:

Biopsy report:

  • Metaplasia in the lower 1/3 of the esophagus for 5cm.
  • No dysplasia or neoplasia
  • Endoscopy is recommended for every 3 years.

Approach:

  1. Initial approach
  2. Explain the purpose of consultation
  3. Paraphrase the scenario and ask: “I understand that you had endoscopy done”. Did they tell you reasons why an endoscopy was performed?
  4. Explain the results of endoscopy. Endoscopy shows that you have a condition called Barrett’s esophagus. Barrett’s esophagus is formed by repeated damage by stomach acid to the esophagus. Over years the damage can lead to changes in the cells lining of the esophagus.
  5. Unfortunately, these abnormal cells are at increased risk of becoming cancerous in future., but the risk is small.
  6. Because of the increased risk, it is recommended that we perform endoscopy every 3 years.
  7. If the abnormal cells become cancer cells, then they will be discovered at an early stage and treatment such as operation may be offered.
  8. At this stage, we just need to stop anything that may contribute to the development of any cancer.
  9. At the moment, these abnormal cells are not cancer.
  10. Alcohol: Drinking too much alcohol causes irritation and inflammation in the lining of the esophagus.
  11. Smoking: Tobacco smoke contains many harmful toxins and chemicals. These substances irritate the cells that make up the lining of the esophagus, which increases the likelihood that they will become cancerous. The longer you smoke, the greater the risk of developing cancer of the esophagus.
  12. Obesity: If you are overweight or obese, your risk of developing cancer of the esophagus is higher that people of healthy weight.
  13. Diet: Not eating enough fruit and vegetables may increase the risk of getting esophageal cancer.
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Who you are:
You are FY2 in GP clinic.

Who the patient is:
Mr David Smith is 55 years old, he had endoscopy a week ago which showed Barrett’s oesophagus.

What you should do:
Explain the results to him and talk to him about the surveillance (each 3 years)

Hello, I am one of the doctors here. May I confirm your full name and your date of birth?
I can see from my notes that you are here for your result, I have your results but if you do not mind, can we have a chat about your health ?
Why did you have this camera test?

P: For heart burn (ODIPARA)

  • Explore
  • Any change in your symptoms since you did the test ?
  • Anything else ?

DDs:

  • Difficulty swallowing ?
  • Change in your voice ?
  • Nausea or vomiting ?

FLAWS: Very important (it’s Barrett’s- a pre- cancerous disease)

How was the test ?
Did you experience any challenges? Any problems afterwards?
Any pain or vomiting blood after the test ?
Any medical conditions ? ( stomach ulcer )

DESA: Smoking/ alcohol increase risk of cancerous transformation so you will have to counsel about them. Spicy food, chocolate, coffee, fried food, fizzy drinks and being overweight can make symptoms worse.

MAFTOSA: stress can make symptoms worse, so advise and offer options.

Examination:
− Observation
− BMI
− Tummy

(Explain the results)
Unfortunately, the result shows that you have a condition called Barrett’s oesophagus. The Oesophagus is your food pipe and due to a long time reflux of acid from the stomach to its lower part, it causes a change in the shape of its cells. Let me assure you this change in itself is not malignant or cancerous and could remain constant in many people; However, it has a higher potential to become a cancer compared to other normal cells. So we will need to perform a similar endoscopy to monitor it every 3 years to pick up any serious changes as early as possible and manage them properly.

Management: A R M M S

Advice:

  • Reduce weight to improve symptoms.
  • Avoid eating or drinking couple of hours before bedtime.

Risk factors

  • Smoking → has chemical that can damage your food pipe → We can refer you to smoking cessation clinic.
  • Alcohol → better to cut down or follow the recommended weekly
    amount (14 units per week and not more than 2-3 units per day) to improve your symptoms.
  • Food → Avoid certain food can increase the heartburn such as : (spicy – fats – coffee)
    • Small frequent meals
    • 5 potions of fruits and vegetables

Management and investigations:

  • I will inform my senior because, you might need medication for your heartburn ( PPI )
    • H – pylori test

Multidisciplinary: We need to keep monitoring it by performing a camera test
at regular intervals and we might take a sample for further examination under
microscope.

Safety netting:

  • Worsening of your symptoms
  • Difficulty swallowing
  • Losing weight

P: Why you do not remove them?
D; That’s a good question. The food pipe is an important structure in our body and surgery is not recommended at this stage as it has a low risk of turning into cancer. We will keep monitoring you and if, at any time, we found any abnormality, we can deal with it in its early stages.

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