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{{WBRQuestion
{{WBRQuestion
|QuestionAuthor={{Rim}}
|QuestionAuthor={{YD}} (Reviewed by {{YD}})
|ExamType=USMLE Step 1
|ExamType=USMLE Step 1
|MainCategory=Pathology
|MainCategory=Pathology
Line 21: Line 21:
|MainCategory=Pathology
|MainCategory=Pathology
|SubCategory=Gastrointestinal
|SubCategory=Gastrointestinal
|Prompt=A 56 year old male patient, known to be a heavy cigarette smoker and with a significant past medical history of type 2 diabetes mellitus, presents to the physician's office complaining of long-standing heartburn. Upon further questioning, the physician requests gastroscopy with biopsies in the proximal, mid, and distal thirds of the esophagus. A representative sample of the patient's esophageal biopsies is shown in the image below.  Which of the following best describes the patient's condition?
|Prompt=A 56-year-old obese Caucasian man with a significant past medical history of well-controlled type 2 diabetes mellitus presents to the physician's office for long-standing heartburn. The patient reports he is a heavy cigarette smoker and drinks 1-2 beers each day. Upon further questioning, the physician requests a gastroscopy with biopsies in the proximal, mid, and distal thirds of the esophagus. A representative sample of the patient's esophageal biopsies is shown in the image below.  Which of the following best describes the patient's condition?


[[Image:WBR_Barrett.jpg|600px]]
[[Image:WBR_Barrett.jpg|600px]]
|Explanation=Barrett's esophagus is a form of glandular metaplasia defined as the presence of columnar epithelium resembling that of the duodenum that lines the distal esophagus instead of the normal nonkeratinized stratified squamous epithelium. It is a common complication of long-standing gastroesophageal reflux disease (GERD). The definitive diagnosis of Barrett's esophagus is based on endoscopic biopsy of the distal esophagus. It is in fact of clinical concern due to its predisposition to adenocarcinoma of the esophagus, which justifies why close follow-up with subsequent endoscopies is indicated once the diagnosis is made. Treatment and prevention of dysplasia is by aggressive management of GERD and inhibition of the overproduction of gastric acids.
|Explanation=Barrett's esophagus is a premalignant lesion among the majority of patients with esophageal adenocarcinoma. Barrett's esophagus is a form of glandular metaplasia, defined as loss of the normal non-keratinized stratified squamous epithelium of the distal esophagus. Instead, the epithelium is replaced by  abnormal glandular columnar epithelium which resembles that of the duodenum.  
 
Healthy individuals have a gastroesophageal (GE) junction and squamocolumnar junction at the same level. The definitive diagnosis of Barrett's esophagus is based on endoscopic biopsy of the distal esophagus. Barrett's esophagus is a clinical concern due to its predisposition to adenocarcinoma of the esophagus. Barrett's esophagus is a common complication of long-standing gastroesophageal reflux disease (GERD). In addition to GERD and GERD symptoms, the most important risk factors for the development of Barrett's esophagus include obesity, advanced age, male sex, white race. Patients with Barrett's esophagus are approximately 30-40 times more likely to develop esophageal adenocarcinoma compared to patients with no Barrett's esophagus. which justifies why close follow-up with subsequent endoscopies is indicated once the diagnosis is made. Treatment and prevention of dysplasia is by aggressive management of GERD and by inhibiting the overproduction of gastric acids.
|AnswerA=Metaplasia
|AnswerA=Metaplasia
|AnswerAExp=Barrett's esophagus is a form of glandular metaplasia that transforms esophageal nonkeratinized stratified squamous epithelium into glandular columnar epithelium.
|AnswerAExp=Barrett's esophagus is a form of glandular metaplasia whereby esophageal nonkeratinized stratified squamous epithelium is replaced by glandular columnar epithelium.
|AnswerB=Dysplasia
|AnswerB=Dysplasia
|AnswerBExp=Dysplasia is a reversible abnormal growth with loss of cellular shape, size, and orientation. Barrett's esophagus, per se, is not a form of dysplasia.
|AnswerBExp=Dysplasia is a reversible abnormal growth with loss of cellular shape, size, and orientation. Barrett's esophagus, ''per se'', is not a form of dysplasia. Nonetheless, long-standing Barrett's esophagus may result in low grade dysplasia, then high grade dysplasia, and finally esophageal adenocarcinoma.
|AnswerC=Desmoplasia
|AnswerC=Desmoplasia
|AnswerCExp=Desmoplasia is the formation of fibrous tissue in a neoplasm. Barrett's esophagus, per se, is not a form of desmoplasia
|AnswerCExp=Desmoplasia is the formation of fibrous or connective tissue usually secondary to a neoplasm. Barrett's esophagus is not a form of desmoplasia. Several cutaneous and visceral cancers may be associated with desmoplasia..
|AnswerD=Neoplasia
|AnswerD=Neoplasia
|AnswerDExp=Neoplasia is the irreversible clonal proliferation of cells with uncontrolled growth. Barrett's esophagus, per se, is not a form of neoplasia. However, it can lead to adenocarcinoma.
|AnswerDExp=Neoplasia is the irreversible clonal proliferation of cells with uncontrolled growth. Barrett's esophagus is not a form of neoplasia. However, it can result in adenocarcinoma.
|AnswerE=Hyperplasia
|AnswerE=Hyperplasia
|AnswerEExp=Hyperplasia is defined as the increase in the number of cells. Barrett's esophagus, per se, is not a form of hyperplasia.
|AnswerEExp=Hyperplasia is defined as tissue growth due to the increase in the number of cells. Barrett's esophagus is not a form of hyperplasia. An example of hyperplasia is benign prostate hyperplasia (BPH) among men older than 50 years of age.
|EducationalObjectives=Barrett's esophagus is a metaplasia defined as the presence of columnar epithelium that lines the distal esophagus.
|EducationalObjectives=Barrett's esophagus is a metaplasia defined as the presence of columnar epithelium that lines the distal esophagus.
|References=Sjogren RW, Johnson LF. Barrett's esophagus: a review. Am J of Med. 1983; 74(2):313-321.
|References=Sharma P. Barrett's esophagus. N Engl J Med. 2009;361:2548-56.<br>
Sjogren RW, Johnson LF. Barrett's esophagus: a review. Am J of Med. 1983; 74(2):313-321.<br>
First Aid 2014 page 350
|RightAnswer=A
|RightAnswer=A
|WBRKeyword=Barrett's, Barrett, Esophagus, Metaplasia, Hyperplasia, Dysplasia, Neoplasia, Desmoplasia, Glandular, Adenocarcinoma, GERD, Gastroesophageal, Reflux, Disease, Heartburn, Columnar, Epithelium
|WBRKeyword=Barrett's, Barrett, Esophagus, Metaplasia, Hyperplasia, Dysplasia, Neoplasia, Desmoplasia, Glandular, Adenocarcinoma, GERD, Gastroesophageal, Reflux, Disease, Heartburn, Columnar, Epithelium
|Approved=Yes
|Approved=Yes
}}
}}

Revision as of 15:30, 13 October 2014
Author [[PageAuthor::Yazan Daaboul, M.D. (Reviewed by Yazan Daaboul, M.D.)]]
Exam Type ExamType::USMLE Step 1
Main Category MainCategory::Pathology
Sub Category SubCategory::Gastrointestinal
Prompt [[Prompt::A 56-year-old obese Caucasian man with a significant past medical history of well-controlled type 2 diabetes mellitus presents to the physician's office for long-standing heartburn. The patient reports he is a heavy cigarette smoker and drinks 1-2 beers each day. Upon further questioning, the physician requests a gastroscopy with biopsies in the proximal, mid, and distal thirds of the esophagus. A representative sample of the patient's esophageal biopsies is shown in the image below. Which of the following best describes the patient's condition?

]]

Answer A AnswerA::Metaplasia
Answer A Explanation AnswerAExp::Barrett's esophagus is a form of glandular metaplasia whereby esophageal nonkeratinized stratified squamous epithelium is replaced by glandular columnar epithelium.
Answer B AnswerB::Dysplasia
Answer B Explanation [[AnswerBExp::Dysplasia is a reversible abnormal growth with loss of cellular shape, size, and orientation. Barrett's esophagus, per se, is not a form of dysplasia. Nonetheless, long-standing Barrett's esophagus may result in low grade dysplasia, then high grade dysplasia, and finally esophageal adenocarcinoma.]]
Answer C AnswerC::Desmoplasia
Answer C Explanation AnswerCExp::Desmoplasia is the formation of fibrous or connective tissue usually secondary to a neoplasm. Barrett's esophagus is not a form of desmoplasia. Several cutaneous and visceral cancers may be associated with desmoplasia..
Answer D AnswerD::Neoplasia
Answer D Explanation AnswerDExp::Neoplasia is the irreversible clonal proliferation of cells with uncontrolled growth. Barrett's esophagus is not a form of neoplasia. However, it can result in adenocarcinoma.
Answer E AnswerE::Hyperplasia
Answer E Explanation AnswerEExp::Hyperplasia is defined as tissue growth due to the increase in the number of cells. Barrett's esophagus is not a form of hyperplasia. An example of hyperplasia is benign prostate hyperplasia (BPH) among men older than 50 years of age.
Right Answer RightAnswer::A
Explanation [[Explanation::Barrett's esophagus is a premalignant lesion among the majority of patients with esophageal adenocarcinoma. Barrett's esophagus is a form of glandular metaplasia, defined as loss of the normal non-keratinized stratified squamous epithelium of the distal esophagus. Instead, the epithelium is replaced by abnormal glandular columnar epithelium which resembles that of the duodenum.

Healthy individuals have a gastroesophageal (GE) junction and squamocolumnar junction at the same level. The definitive diagnosis of Barrett's esophagus is based on endoscopic biopsy of the distal esophagus. Barrett's esophagus is a clinical concern due to its predisposition to adenocarcinoma of the esophagus. Barrett's esophagus is a common complication of long-standing gastroesophageal reflux disease (GERD). In addition to GERD and GERD symptoms, the most important risk factors for the development of Barrett's esophagus include obesity, advanced age, male sex, white race. Patients with Barrett's esophagus are approximately 30-40 times more likely to develop esophageal adenocarcinoma compared to patients with no Barrett's esophagus. which justifies why close follow-up with subsequent endoscopies is indicated once the diagnosis is made. Treatment and prevention of dysplasia is by aggressive management of GERD and by inhibiting the overproduction of gastric acids.
Educational Objective: Barrett's esophagus is a metaplasia defined as the presence of columnar epithelium that lines the distal esophagus.
References: Sharma P. Barrett's esophagus. N Engl J Med. 2009;361:2548-56.
Sjogren RW, Johnson LF. Barrett's esophagus: a review. Am J of Med. 1983; 74(2):313-321.
First Aid 2014 page 350]]

Approved Approved::Yes
Keyword WBRKeyword::Barrett's, WBRKeyword::Barrett, WBRKeyword::Esophagus, WBRKeyword::Metaplasia, WBRKeyword::Hyperplasia, WBRKeyword::Dysplasia, WBRKeyword::Neoplasia, WBRKeyword::Desmoplasia, WBRKeyword::Glandular, WBRKeyword::Adenocarcinoma, WBRKeyword::GERD, WBRKeyword::Gastroesophageal, WBRKeyword::Reflux, WBRKeyword::Disease, WBRKeyword::Heartburn, WBRKeyword::Columnar, WBRKeyword::Epithelium
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