GASTROESOPHAGEAL REFLUX

DISEASE
Heba Mohammed Abdella
Professor of Tropical Medicine, Ain Shams University
What is GERD?
• GERD develops when the reflux of stomach
contents causes troublesome symptoms or
complications.
• This means that GERD is defined by a
constellation of both symptoms or objective
findings such as esophageal erosions or
Barrett’s esophagus.
Is GERD a common disease?
• GERD is one of the most common disorders of GIT.
• In developed countries, the prevalence of GERD (defined by symptoms
of heartburn, acid regurgitation, or both, at least once a week) is 10%
to 20%, whereas.
• In Asia the prevalence is roughly < 5%.
• In the US, this disease is the most common GI diagnosis to prompt an
outpatient clinic visit (8.9 million visits in 2009).
• The rising prevalence of GERD seems to be related to the rapidly
increasing prevalence of obesity, which includes increasing abdominal
girth and the resulting pressure-induced relaxation of the lower
esophageal sphincter (LES), causing reflux.
 Is GERD
an • GERD has become an important
public health problem because it:
importan 1.Impairs quality of life
2.Creates a considerable economic
t public burden
health 3.Reduces productivity
4.Requires medications and
problem consultations.

?
 What are the most typical symptoms of GERD?

The two most typical • heartburn (pyrosis) and regurgitation.

symptoms of GERD are:

Heartburn is • a painful retrosternal burning sensation of fairly short

characterized by duration (several minutes).

Regurgitation is • backflow of gastric content into the mouth, not associated

defined as with nausea or retching.

Some patients perceive • angina-like chest pain, but this symptom requires thorough
their reflux episodes as evaluation for a cardiac cause before GERD is considered.
What are the other typical
symptoms of GERD?
• Water brash is the sudden appearance in
the mouth of a slightly sour or salty fluid.
• It is not regurgitated fluid, but rather
vagally mediated secretions from the
salivary glands in response to acid reflux.
Dysphagia:
• is seen in up to 40% of patients with long-standing GERD
• may herald the presence of an esophageal stricture, esophageal dysmotility,
ring, or even esophageal carcinoma.
• is an alarm symptom or warning sign and an indication for early endoscopy to
rule out a GERD complication.

Odynophagia:
• is usually described as a sharp or lancinating pain located behind the sternum.
• Although severe erosive esophagitis or esophageal ulceration from reflux can
cause painful swallowing, both are uncommon causes of odynophagia.
• Its presence should raise the suspicion of an alternative cause of esophagitis,
especially infections or injury from impacted pills.
 What are the extraesophageal
manifestations of GERD?
Chronic cough, asthma, chronic laryngitis, dental erosion, chronic obstructive pulmonary
disease, hoarseness, globus, postnasal drip disease, sinusitis, otitis media, recurrent
pneumonia, and laryngeal cancer are the extraesophageal manifestations of GERD.

These symptoms may occur concomitantly with typical symptoms or in isolation.

The latter results in delayed diagnosis of reflux as a potential contributing factor to

patients’ symptoms.
 What
other • Infectious esophagitis, pill
diseases esophagitis, eosinophilic
esophagitis, PUD, nonulcer
should be dyspepsia, biliary tract disease,
coronary artery disease, and
considere esophageal motor disorders.
d in the • Symptoms alone do not reliably
DD of distinguish among these disorders.

GERD?
Which mechanisms are involved in the pathophysiologic findings of GERD?
• Dysfunction of the esophagogastric junction,
• Esophageal body dysfunction,
• Delayed gastric emptying,
• Increased intragastric pressure,
• Acid pocket,
• Eophageal hypersensitivity

The two most common pathophysiologic mechanisms include

TLESR which is the most common cause

Reduced LES pressure caused by hiatal hernia, which is more

common in patients with Barrett’s esophagus.
 Where is the LES? What is the function of the LES?
• The LES involves the distal 3 to 4 cm of the esophagus and at rest is tonically
contracted.
• It is the major component of the antireflux barrier, being capable of preventing
reflux even when completely displaced from the diaphragmatic crura by a hiatal
hernia.
• The proximal portion of the LES is normally 1.5 to 2 cm above the
squamocolumnar junction, whereas the distal segment, approximately 2 cm in
length, lies within the abdominal cavity.
• This location maintains gastroesophageal competence during intraabdominal
pressure excursions.
• Resting LES pressure ranges from 10 to 35 mmHg with a generous reserve capacity
because only a pressure of 5 to 10 mm Hg is necessary to prevent GERD.
 • In healthy people, an anatomic flap valve is
present at the esophagogastric junction, which
functions to keep the distal part of the LES in the
abdomen and to maintain the angle of His (i.e.,
the acute angle between the entrance to the
What is the stomach and the esophagus).
anatomic flap • As the flap valve disrupts and the LES moves
valve? above the crural canal, the high-pressure zone
loses its synergistic configuration and both
sphincters (LES and diaphragm) become
appreciably weaker.
What is the importance of obesity in the
development of GERD?
• Obesity augments the risk of reflux symptoms, prolonged
esophageal acid exposure, esophagitis, and Barrett’s
esophagus, and that increased abdominal pressure is the
pivotal mechanistic factor.
• Obesity results in an increased incidence of TLESR, which
in turn results in increasing acid reflux and predisposes
patients to complications of GERD such as esophagitis,
Barrett’s esophagus, and even adenocarcinoma.
What is the acid pocket?

• In the postprandial period, a layer of unbuffered acidic

gastric juice sits on top of the meal, close to the cardia,
ready to reflux.
• This occurrence has become known as the acid pocket
and is facilitated by an absence of peristaltic contractions
in the proximal stomach.
• In patients with GERD, the acid pocket is located more
proximally with respect to the squamocolumnar
junction, and it could even extend above the
manometrically defined LES.
Does
esophageal Hypersensitivity to acid
hypersensitivity occurs both in people with
to acid occur erosive esophagitis and in
only in people those with a
with erosive macroscopically normal
esophagitis?
mucosa.

Factors contributing to the Impaired mucosal barrier

noted increased function,
esophageal sensitivity are: Upregulation of peripheral
nociceptors,
Central sensitization.
Is there any relationship between H.pylori
and GERD?
• H. pylori does not have an important role in the
pathogenesis of GERD.
• Eradication of the microorganism does not lead to an
increased chance of development of the disorder.
• Patients with H. pylori should be treated to eradicate the
organism, which is important in the development and
recurrence of peptic ulcer disease and gastric malignancy.
What are the diagnostic methods for GERD?

The diagnosis of GERD is made using a combination of:

1. Symptom presentation,
2. Objective testing with endoscopy,
3. Ambulatory reflux monitoring,
4. Response to antisecretory therapy.

The symptoms of heartburn and regurgitation are

• The most reliable for making a presumptive diagnosis based on history alone.

Empiric therapy with acid suppressive therapy and response to such therapy
• is considered an important indication for presence of GERD.

Diagnostic testing with endoscopy and pH monitoring are typically reserved for
• those who are either unresponsive or suboptimally responsive to acid suppressive therapy.
 What is the most reasonable
approach to confirm the diagnosis of
GERD?
Empiric PPI therapy (termed PPI trial) is a reasonable approach
to confirm GERD when it is suspected in patients with typical
symptoms.
However, the PPI trial might also be positive in other acid-related disorders, such as peptic ulcer
disease and functional dyspepsia, and an important placebo effect has been seen.

Therefore the specificity of the test is poor (24%-65%) and is not higher than that of testing with
placebo (38%-41%).

Nonetheless, in primary care, a short trial of a PPI is deemed useful, because the combination of a
favorable response and absence of alarm symptoms makes additional diagnostic testing unnecessary.
 Are barium radiograph and esophageal
manometry used in the diagnosis of GERD?
Esophageal manometry is
Barium radiographs should not be recommended for preoperative
performed to diagnose GERD without
dysphagia. evaluation, but has no role in
the diagnosis of GERD.
Is upper endoscopy required for the initial diagnosis of GERD?

Upper endoscopy is not required in the presence of typical

GERD symptoms.

Endoscopy is recommended in the presence of alarm

symptoms (dysphagia, gastrointestinal bleeding, weight
loss, anemia, recurrent vomiting, etc.) and for screening
patients at high risk for complications.

Repeat endoscopy is not indicated in patients without

Barrett’s esophagus in the absence of new symptoms.
Is there a benefit of histologic analysis for
diagnosis of GERD?
• Routine biopsies from the distal esophagus are not
recommended specifically to diagnose GERD.
• Biopsy samples should therefore only be taken when
other causes of esophagitis are being considered.
• In young patients with suspected eosinophilic
esophagitis, biopsies should be taken for confirmation
of the diagnosis.
 Why is upper endoscopy performed in
patients with GERD?
For example, the test
serves to rule out
Upper endoscopy should
alternative diagnoses, such
be performed in refractory However, erosive
as eosinophilic esophagitis,
patients with typical or esophagitis is only found in
infection, and pill injury;
dyspeptic symptoms approximately 30% of
furthermore, an
principally to exclude non- untreated GERD patients.
observation of typical
GERD etiologic factors.
reflux esophagitis confirms
the diagnosis of GERD.
How is the severity of endoscopic reflux esophagitis classified?
• GERD can be classified as the presence of symptoms without erosions on endoscopic
examination (nonerosive reflux disease [NERD]) or GERD symptoms with erosions
present (erosive reflux disease).

The severity of endoscopically observed reflux esophagitis is graded

with the Los Angeles classification.
• Grade A: One or more mucosal breaks confined to folds, 5 mm or smaller.
• Grade B: One or more mucosal breaks larger than 5 mm confined to folds but not
continuous between tops of mucosal folds.
• Grade C: Mucosal breaks continuous between tops of two or more mucosal folds but
less than 75% of esophageal circumference is involved.
• Grade D: Mucosal breaks encompass more than 75% of esophageal circumference.
Los Angeles classification of grades A–D esophagitis
 What are
• It is indicated before consideration of
the endoscopic or surgical therapy in patients
indications with NERD, as part of the evaluation of
patients refractory to PPI therapy, and in
of situations in which the diagnosis of GERD
is in question.
ambulatory • It may also be performed in those who
esophageal have undergone surgical fundoplication
whose symptoms have returned to assess
reflux if the wrap is loosened.
monitoring?
What is the • The effectiveness of dietary
modifications has not been shown,
effectivenes and in view of this absence of
evidence, limitation of dietary advice
seems wise.
s of the • Thus cessation of fatty foods,
chocolate, caffeine, spicy foods,
dietary peppermint, citrus, and carbonated
beverages is not routinely
modification recommended for GERD patients.
• Selective elimination could be

s for GERD considered if patients note

correlation with GERD symptoms and
improvement with elimination.
patients?
 • Cessation of tobacco smoking and alcohol
Is lifestyle drinking is a sensible recommendation in
general, but no data show that stopping
modificatio smoking and alcohol drinking leads to a
reduction in reflux symptoms.
n helpful • By contrast, much evidence indicates the
effectiveness of weight reduction, at least in
for GERD patients who are overweight or obese.
• The frequent advice to elevate the head of the
patients? bed is only rational for patients with GERD who
have reflux episodes at night.
What are the medical options for patients failing
dietary and lifestyle interventions?

Antacids, H2RAs, or PPI.

In the past step-up therapy was recommended in which patients were first
treated with antacids and lifestyle modifications followed by H2RAs and
PPIs.

However, current recommendations are in favor of step-down therapy in

which PPI therapy is the first option followed by tapering to H2RAs and
antacids if possible.
 How should we treat patients with moderate to
severe symptoms of GERD or severe erosive
esophagitis?

8 week treatment with PPIs should be regarded as first-line treatment.

There is lear advantage of PPIs (omeprazole,

Patients with severe esophagitis may need lifelong
lansoprazole, rabeprazole, pantoprazole, esomeprazole,
therapy with acid suppressive medications because
and dexlansoprazole) over H2 blockers for both healing
recurrence of esophagitis is common off therapy.
of esophagitis and maintenance of healing.
Is PPI treatment safe?

• PPI treatment is very safe.

However, over the years, some concerns about the effects of
prolonged acid suppression have been raised, including a high risk
of
• Infection,
• Enhanced propensity to develop atrophic gastritis,
• Encreased risk of Clostridium difficile–associated diarrhea,
• Greater risk of fractures,
• Hypomagnesemia, deficiencies of vitamin B12 and iron,
• The potential for a transient increase in acid secretion after discontinuation.
Clinically important drug interactions are rare.
The platelet aggregation inhibitor clopidogrel is less active in
conjunction with PPI treatment because of decreased activation.
However, recent work suggests that this interaction is not clinically
relevant.
Overall, we must be selective on the use of PPI therapy and limit it to
those who need it and who cannot be tapered off therapy because of
recurrence of symptoms or esophagitis.
Are the currently available prokinetics effective
for treatment of GERD?
• The currently available prokinetics metoclopramide and
domperidone are not effective for treatment of this
disease.
• Cisapride was an effective drug but is no longer available.
• New prokinetics are in development today.
• The main role of this class of agents is in those with
gastroparesis.
 What are the
• Currently available techniques for endoscopic
techniques for treatment of GERD include suturing devices,
endoscopic transmural fasteners and staplers, and
radiofrequency ablation.
treatment of • Although the techniques all seem feasible and
have safety profiles similar to those of antireflux
GERD? What is surgery, they are not as effective as surgery for
the returning acid exposure to normal, healing of
esophagitis, and resolution of symptoms.
effectiveness of • Long-term results with endoscopic therapies
may not be as good as the gold standard of
these surgical fundoplication.
treatments?
What are the indications for surgery in patients with GERD?

Reasons to refer GERD patients for surgery may include

1.Desire to discontinue medical therapy,

2.Noncompliance, side effects associated with medical therapy,
3.The presence of a large hiatal hernia,
4.Esophagitis refractory to medical therapy,
5.Persistent symptoms documented to be caused by refractory GERD (mainly caused by
continued regurgitations).

Fundoplication has also proven effective in patients for whom nonacid

reflux (regurgitation) is an important determinant of symptoms.
Preoperative ambulatory pH monitoring is mandatory in patients
without evidence of erosive esophagitis.
All patients should undergo preoperative manometry to rule out
achalasia or scleroderma-like esophagus.
Surgical therapy is as effective as medical therapy for carefully
selected patients with chronic GERD when performed by an
experienced surgeon.
 What is the management algorithm for GERD patients with alarm or refractory symptoms?

After endoscopy,

patients undergo a trial of single-dose PPI, but when this approach has already been
tried,

twice-daily PPI therapy (off-label indication) is started.

When the response to PPI is satisfactory

patients with severe esophagitis and Barrett’s esophagus should continue with daily PPI (maintenance treatment),
whereas those with no or mild esophagitis can use a PPI on demand or taper acid-suppressive therapy to H2RAs.
 When symptoms persist despite a sufficiently long period with high-
dose PPI, the next step is to

investigate whether symptoms are truly the result of reflux, using

ambulatory reflux monitoring.

The outcomes are either that

that symptoms are the or more commonly that

the patient’s symptoms are
result of insufficient reflux they are caused by non-
not related to reflux,
therapy, GERD-related causes.
What are the complications associated with GERD?

The complications of GERD can be broadly divided

into three categories:
• Esophagitis, which can be associated with a variety of symptoms,
including heartburn, regurgitation, and dysphagia.
• Consequences of the reparative process of esophagitis (peptic
stricture and Barrett’s metaplasia)
• Extraesophageal manifestations of reflux, such as asthma,
laryngitis, and cough
Management algorithm for symptoms of refractory reflux.
What is the approach to treatment of peptic stricture?
The approach to treatment depends on the cause and characteristics of the
stricture and usually includes acid suppression, with at least daily PPI, and dilation
therapy.
The choice of dilator (bougie or balloon) depends on the experience of the
endoscopist; most strictures can be managed with either.
Complicated strictures might need a combination of approaches and repeated
sessions.
Refractory strictures are those not responding to repeated sessions (usually
three).
An intralesional steroid injection or placement of an endoprosthesis might be
needed in such cases; however, data for these techniques are limited.
What is Barrett’s esophagus? How is Barrett’s esophagus
managed?
• It is a complication of GERD in which potentially precancerous
metaplastic columnar cells replace the normal squamous mucosa.
• Barrett’s can be found in 5% to 15% of patients who have endoscopy for
symptoms of GERD and tends to be seen at the higher end of this range
in patients with long duration of symptoms who are white men older
than 50.
• The American Gastroenterology Association supports intervals of 3–5
years if no evidence of dysplasia is seen and a shorter interval for low-
grade dysplasia (6 months) and high-grade dysplasia (3 months or
intervention).
The endoscopic ablation is a viable option for some
patients with high-grade dysplasia.

However, data for endoscopic ablation in Barrett’s

esophagus without dysplasia are not supported by
evidence.

Patients with Barrett’s esophagus with no dysplasia

should be treated with once-daily PPI therapy for life.
How is Barrett’s esophagus defined?
• The presence of columnar metaplasia of the anatomic
esophagus.
• It is a complication of GERD.
• The current American Gastroenterological Association
guideline defines Barrett’s esophagus as a condition in
which any extent of metaplastic columnar epithelium
that predisposes to cancer development replaces the
stratified squamous epithelium that normally lines the
distal esophagus.
This is consistent with an international consensus definition
of Barrett’s esophagus that defines Barrett’s esophagus as
the partial replacement, from the gastroesophageal
junction proximally, of esophageal squamous epithelium
with metaplastic columnar epithelium.

It is important to realize that both these definitions depart

from the traditional view that the presence of intestinal
metaplasia is a prerequisite for the diagnosis of Barrett’s
esophagus.
 Why is • Barrett’s esophagus is a precancerous lesion.
Barrett’s • Identification of dysplasia in Barrett’s
esophagus allows intervention at an early
esophagu stage with good outcomes.
• On the other hand, advanced esophageal
s cancer has a poor prognosis.
• Surveillance using endoscopy is the
important cornerstone of management and allows
patients to be detected at an early stage.
?
 • Age > 50 years
• Male gender
• White race
What are the risk •
factors for Barrett’s
Chronic GERD
esophagus? • Hiatal hernia
• High BMI
• Truncal obesity
What is the endoscopic
appearance and characterization of
Barrett’s esophagus?
• Barrett’s esophagus has a typical
endoscopic appearance.
• It is generally described as a salmon or pink
color within the tubular esophagus, in
contrast to the light gray appearance of
esophageal squamous mucosa.
• It should be emphasized that histologic
examination of esophageal biopsy samples
is required to confirm the diagnosis of
Barrett’s esophagus.
What is the endoscopic appearance and
characterization of Barrett’s esophagus?
• The Prague Classification is a standardized method of
reporting the extent of Barrett’s esophagus and is
recommended for routine endoscopy.
• The vertical extent of Barrett’s epithelium that is
circumferential is measured from the top of the gastric
folds and designated as the C length.
• Longitudinal columns of Barrett’s epithelium are
designated by the letter M, followed by the vertical length.
Short-segment Barrett’s esophagus is defined by the
presence of intestinal metaplasia identified in biopsies
obtained from the esophagus with an endoscopic
appearance suggestive of Barrett’s that extends less than
3 cm into the esophagus.

Long-segment Barrett’s esophagus is defined by segments

of abnormal epithelium longer than 3 cm.
Diagrammatic representation of endoscopic Barrett’s esophagus showing an area
classified as C2M5. C, extent of circumferential metaplasia; GEJ, gastroesophageal
junction; M, maximal extent of the metaplasia (C plus a distal “tongue” of 3 cm).
What is the risk of cancer in Barrett’s esophagus?

0.5% per year, which means that approximately 1 in 200 patients with Barrett’s
esophagus will develop esophageal cancer each year.

Recent studies, however, suggest that the risk may be substantially lower than
originally estimated.
 What are the risk factors for the development
of dysplasia and cancer in Barrett’s esophagus?
There is good
It is uncertain if the
evidence to suggest
risk increases or Obesity
a higher risk for
decreases with the (particularly truncal Smoking increases
patients with long-
passage of time, but obesity) is a major the risk in some
segment Barrett’s
dysplasia and risk factor that is studies but not in
esophagus and a
cancer are typically amenable to others.
greater risk in men
found after the age intervention.
compared with
of 50.
women.
 Does • No high-level evidence.
medical • Treatment with PPI has been shown to
therapy reduce the risk of dysplasia and cancer
in observational studies.
prevent the • Epidemiologic studies suggest a
risk of decrease in the risk of cancer in users of
low-dose aspirin or statins but these
dysplasia or await confirmation in ongoing trials.
cancer?
 Is there a • There is no consensus on whether
role for screening should be recommended
and at what age and what intervals.
screening • Despite the absence of evidence or
cost-effectiveness data, the concept
upper of a “once in a lifetime” endoscopy
to look for Barrett’s esophagus has
endoscopy gained popularity and is widely
followed in the US.
• If this is done, the yield is probably
to identify greatest at or about the age of 50
years.
Barrett’s
esophagus?
What is the goal of medical treatment in
Barrett’s esophagus?

• (1) Treat the symptoms of GERD commonly

The goal of associated with Barrett’s esophagus.
medical • (2) Prevent complications by decreasing mucosal
inflammation in the esophagus.
treatment is • (3)Monitor the patient for the development of
dysplasia or cancer of the esophagus so that
to: early intervention may be offered to the patient.
What is the recommendation for surveillance in Barrett’s
esophagus?
Surveillance of dysplastic Barrett’s esophagus should not be
considered a definitive treatment and ablative therapies should be
considered when dysplasia is identified.

No dysplasia 3-5 years

Low-grade dysplasia 6-12 months

High-grade dysplasia 3 months (in the absence of ablation therapy)

 • Endoscopic evaluation is recommended using white light
What is the endoscopy.
• High-definition endoscopes and narrow band imaging can
recommende help identify surface abnormalities that require targeted
biopsies.
d biopsy • Current recommendations are that four-quadrant biopsy
specimens be taken every 2 cm from the Barrett’s
protocol for epithelium.
• Chromoendoscopy is a technique using dye (Methylene
Barrett’s blue or Indigo Carmine) sprayed over the Barrett’s
epithelium to identify surface abnormalities.
esophagus? • Narrow-band imaging uses a narrow spectrum of light that
achieves the same effect.
Narrow band imaging of Barrett’s esophagus. Using a narrow spectrum of light
enhances detail and allows clearer visualization of the surface characteristics. It
allows sharp demarcation from the normal squamous epithelium.
How reliable is the pathologic diagnosis
of high-grade dysplasia?
• It has long been recognized that there is
interobserver variability between pathologists in
identifying high-grade dysplasia and early cancer.
• At least two experienced GIT pathologists should
evaluate all Barrett’s biopsies when a diagnosis of
dysplasia is considered.
What is the management of high-grade
dysplasia in Barrett’s esophagus?
• Endoscopic treatment should be preferred over
endoscopic surveillance.
• Endoscopic therapy is also preferred to surgical
intervention in this setting.
• The commonly used options for endoscopic therapy are
radiofrequency ablation and photodynamic therapy.
• Both have shown a high degree of success in ablating the
dysplastic epithelium and preventing recurrence.
Algorithm for the management of Barrett’s esophagus based on dysplasia identified at histopathologic examination.
 What is the management of early
esophageal cancer in Barrett’s esophagus?
Endoscopic resection of early esophageal cancer is
the preferred treatment when the lesion is confined
to the T1 without vascular or lymphatic spread.

Expert guidance and endoscopic ultrasound to stage

the lesion are mandatory.
How reliable is the pathologic diagnosis of
low-grade dysplasia in Barrett’s esophagus?
• The criteria for the definition of low-grade dysplasia are
not well defined and vary in different regions of the
world.
• There is a tendency to over-diagnose low-grade dysplasia
as a result of misinterpretation of regenerative changes.
• Confirmation of the diagnosis with two pathologists is
essential.
 • Low-grade dysplasia is a risk factor for malignancy.
What is • The risk for progression may have been under
estimated in the past.
the risk of • A recent study showed that many patients with
low-grade dysplasia were down-graded to no
progressio dysplasia after further pathologic review.
• In patients in whom low-grade dysplasia was
n in low- confirmed by pathologic review, the rate of
progression was very high (85%).
grade • The incidence rate of high-grade dysplasia or cancer
was 13.4% per patient per year for patients in
dysplasia? whom the diagnosis of low-grade dysplasia was
confirmed.
 How
should • As regenerative changes can be misinterpreted as dysplastic
changes, confirmation of the diagnosis by a second

low- pathologist is essential.

• In patients who have not been adequately treated for reflux
disease, treatment with PPI followed by repeated biopsy is
grade recommended.
• The confounding effects of inflammation and regeneration
are removed.
dysplasia • Persistent low-grade dysplasia needs careful monitoring for
progression.

be • Many experts believe that, because of the high rate of

progression when low-grade dysplasia is persistent and
confirmed, ablative therapy should be offered to these

managed patients.

?
What future developments are anticipated?
The areas in which progress may be anticipated are:
(1) better diagnosis of dysplasia using cellular markers and
endoscopic biopsy techniques.
(2) Better identification of individuals at risk for progression using
genetics and cellular markers from Barrett’s epithelium.
(3) Noninvasive markers for progression such as serum tests.
(4) Further endoscopic innovations for the management of dysplasia
or cancer.
(5) Pharmacotherapy to decrease the risk of progression or to
prevent the development of Barrett’s esophagus.
Click to edit Master title style
• Edit Master text styles
• Second level
• Third level
• Fourth level
• Fifth level

Thank
You