A 55-year-old white man presents to your office having been referred by a gastroenterologist. The patient has a long-standing history of acid reflux symptoms. He was diagnosed with Barrett’s esophagus 5 years before his clinic visit and had undergone periodic endoscopic surveillance. He was not taking any acid suppression medications because his reflux symptoms were adequately controlled with antacids. Recent endoscopic biopsies demonstrated possible high-grade dysplasia. He has had no previous surgery. His examination is normal.

The gastroenterologist provides you with the results of a barium swallow, which demonstrate a normal esophagus with a small hiatal hernia. The stomach is normal. There was mild reflux of contrast into the esophagus during the examination. Previous endoscopy identified Barrett’s esophagus beginning 30 cm from the incisors and extending to the gastroesophageal junction 35 cm from the incisors. No masses or ulcerations are evident. There is moderate esophagitis proximal to the squamocolumnar junction. There is a small axial hiatal hernia. The stomach and first portion of the duodenum are normal. During the past 3 years, the patient has had periodic endoscopic evaluations with surveillance biopsies. Histologic report is provided as follows.

This patient has a prolonged history of acid reflux symptoms and has had Barrett’s esophagus confirmed on multiple endoscopies. The patient has not taken acid suppression medications regularly and has had esophagitis in each of his biopsies. The finding of a single focus of high-grade dysplasia is suggestive for the possible presence of invasive cancer. It is necessary at this point to reconfirm the diagnosis of high-grade dysplasia. The initial diagnosis of high-grade dysplasia may be erroneous, particularly when it is made in the presence of esophagitis. Other possible diagnoses are Barrett’s esophagus with low-grade dysplasia, Barrett’s esophagus without dysplasia, and invasive adenocarcinoma. The pathology slides should be reviewed by a specialist.

The pathology slides are reviewed by a gastrointestinal pathologist, who confirms the findings of Barrett’s esophagus and esophagitis, but reports no evidence of high-grade dysplasia.