S3567 No Barrett's, No Way! A Case of De novo Esophageal Adenocarcinoma

Abstract

Introduction: Instances of esophageal adenocarcinoma have been increasing at a more drastic rate in the United States and Western Europe in recent years. This calls for more aggressive and comprehensive screening processes for patients with chronic reflux and for those found to have Barrett’s esophagus. Barrett’s esophagus is widely accepted as a precursor to adenocarcinoma of the esophagus, but this case provides a caveat to this rule of thumb. Case Description/Methods: This is a case of a 63-year-old woman who initially presented with severe GERD and was complaining of reflux and regurgitation, as well as nocturnal coughing and wheezing. An endoscopy was conducted revealing LA class 3 esophagitis, a large hiatal hernia, and a distal esophageal inflammatory nodule. The patient was treated aggressively with a combination of a daily PPI and a nightly H2RA. A three-month follow-up endoscopy revealed improvement of her esophagitis, which was downgraded to LA class 1. There was no evidence of Barrett’s esophagus, and the esophageal nodule had healed. Despite this treatment plan the patient was still complaining of regurgitation. An upper GI series revealed a 5 cm hiatal hernia with reflux on water siphon test and valsalva maneuver. Subsequently, a laparoscopic partial fundoplication was performed with complete resolution of all symptoms and successful discontinuance of all acid suppression medications. 2 and ½ years later the patient presented with new onset dysphasia. An upper endoscopy was subsequently performed which revealed a large adenocarcinoma of the distal esophagus and 2 satellite lesions above the adenocarcinoma. Discussion: This case highlights an infrequent presentation of de novo adenocarcinoma with no evidence of Barrett’s esophagus in a conservative time interval. In the chance that the endoscopist may have missed a short segment Barrett’s because of sampling error, the standard of care would have been a 3-year interval surveillance endoscopy. A repeat endoscopy was performed in 2.5 years regardless of no evidence of Barrett’s; the standard of care was not sufficient in this case. This patient exhibited LA class 3-4 distal esophagitis and despite healing, still developed an advanced adenocarcinoma. This may indicate that there is an alternative pathway to esophageal adenocarcinoma in patients with such severe reflux. This case should provide support to potentially screen patients more aggressively who present with severe reflux.Figure 1.: Row 1: initial endoscopy Row 2: second endoscopy Row 3: third endoscopy