The most appropriate next step in management is to repeat upper endoscopy in 3 to 5 years. Although there is no evidence of the benefit of endoscopic screening of the general population, endoscopic assessment for Barrett esophagus (BE) in patients with chronic reflux symptoms may be appropriate in specific patients. It is reasonable to consider screening men older than 50 years with gastroesophageal reflux disease (GERD) symptoms for more than 5 years and additional risk factors (nocturnal reflux symptoms, hiatal hernia, elevated BMI, tobacco use, and intra-abdominal distribution of fat) to detect esophageal adenocarcinoma and BE. This patient is male, older than 50 years, overweight, and is an active smoker; therefore, pursuing screening was reasonable in this patient. His endoscopy revealed BE without evidence of dysplasia. BE is thought to be a complication of GERD resulting in a change in the normal squamous lining of the distal esophagus to a specialized columnar epithelium due to the effect of refluxed gastric secretions. BE is a spectrum ranging from no dysplasia to high-grade dysplasia, and some patients progress to esophageal cancer. Recommended surveillance of patients with newly diagnosed BE is based on the presence and degree of dysplasia on biopsy. In those with no dysplasia, surveillance with upper endoscopy is recommended in 3 to 5 years. In patients with low-grade dysplasia, surveillance is more frequent, usually 6 to 12 months following confirmation by an expert pathologist. High-grade dysplasia requires either more aggressive surveillance or treatment to remove BE (such as with endoscopic ablation or esophagectomy).
Patients with BE with high-grade dysplasia are often treated with endoscopic ablation. This patient has BE with no dysplasia, so this therapy is not appropriate at this time.
Esophagectomy should be reserved for patients in whom endoscopic ablation fails or in those with evidence of esophageal cancer.
Fundoplication is the appropriate treatment for GERD in patients who wish to stop taking medication or in those with a poor response to medical therapy. This patient's symptoms are well controlled on omeprazole, so fundoplication is not appropriate at this time. Fundoplication does not prevent the progression of BE to dysplasia or cancer.