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tracieann
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Quote tracieann Replybullet Topic: BSG guidelines and second opinions
    Posted: 27 Aug 2017 at 5:31pm
i was first diagnosed with 1cm barretts in 2014 there was no intestinal metaplasia present i have been on high dose Rabeprazole since and ranitidine nightly. i had my follow up endoscopy in july this year the 1cm has not changed and still has no intestinal metaplasia or dysplasia thank God BUT i have some small area of intestinal metaplasia by my pylorus . i spoke to the consultant on friday who stated i dont need 3 yearly endos as no metaplasia on oesophagus and said they arent concerned about stomach metaplasia should i ask for a second opinion he grudginly said i would have an endoscopy in 5 years even though i wont really need it can someone please advise i feel nervous about long term
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chrisrob
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Quote chrisrob Replybullet Posted: 27 Aug 2017 at 6:30pm
Ho Tracieann and welcome.

Rabeprazole is one of the more expensive PPIs but is better tolerated than most others. The normal maintenance dose is 20mg and the normal high dose is 40mg daily.
(You may see an equivalence table on the Barrett's Wessex website.)

Barrett's Oesophagus forms as a protection against reflux of acid and bile from the stomach (as described here).
It is composed of columnar cells similar to those that line the stomach (gastric metaplasia) or intestines (intestinal metaplasia).
In UK, as in most countries, any columnar cells (gastric or intestinal) can be regarded as Barrett's. In US, it can only be classified as barrett's if it is identified as Intestinal Metaplasia. The difference bewteen the cells types is the observed existence of "goblet cells".
See this graphic:


The problem is, the cells biopsied are harvested very close to the z-line. That is the junction of the oesophagus and stomach. This is very rarely a clean straight line and often described as irregular. Since the tissue being sampled is elastic, it is very easy for an endoscopist to collect a sample from below the z-line, which will be naturally columnar gastric cells, which a histopathologist may then incorrectly describe as Barrett's.
However, in UK, we still describe gastric metaplasia as Barrett's as it's quite possible the goblet cells have been missed.

I wonder why they decided to biopsy the pylorus? Perhaps you had some inflammation there. Interesting they found intestinal cells here but it's at the junction of the duodenum where they would be expected. The stomach copes with acid OK so there's no real risk if intestinal cells are found in the stomach.

The British Society of Gastro-enterology's guidelines include the following road map of recommendations regarding surveillance scoping:



You will see from this that your consultant was actually correct in suggesting discharging you.

Barrett's is very common in the population. We now think there are likely to be 3 million with it in UK but fewer than 150,000 know it. Although there is a slight risk it can progress to cancer, your small area of metaplasia carries a much smaller risk.
Those of us who know we have Barrett's are the lucky ones. We can take our PPIs regularly (which have been shown to probably reduce the rsks of progression by 71%) and receive surveillance if deemed suitable. It's those who don't know they have it who are most at risk.

You are now aware of the condition and naturally concerned. If you notice any change in symptoms, you will seek further help. If they ever do see any changes ("dysplasia") they will be able to ablate it before it can mutate to cancer.

In the meantime, the Down With Acid is a free resource that will help answer any questions you may have. Email or PM me your address and I'll happily send you a free printed copy.

All the best
Chris
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tracieann
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Quote tracieann Replybullet Posted: 28 Aug 2017 at 8:16am
thank you so much for your wonderfully informing reply myConsultant is a nice man but tends to flit straight through your results without giving you chance to ask anything . so it would be ok for him to discharge me there have been two endoscopies without metaplasia but diagnosed as Barretts epitheliem its confusing Yes the pylorus was biopsied as it was very red and inflamed 3mm micro showed intestinal metaplasia and its scary when they tell you nothing much thank you for the explanation will i be safe having endo in 5 years and Chris thank you for telling me its definately Barretts and that the metaplasia in the pylorus is not as serious as i thought more than my consultant did

Edited by tracieann - 28 Aug 2017 at 8:22am
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chrisrob
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Quote chrisrob Replybullet Posted: 28 Aug 2017 at 8:35am
Most of the consultants I know wish they could spend more time talking with patients but they're on a very tight time schedule. It's also easy for them to forget the patient doesn't know about the condition: they see so many, it becomes a routine to them.

Your case highlights the vagueness surrounding the diagnosis of the condition. Yes, you do have a small area of Barrett's as defined in UK but not if you were in US.

Your risks of progression are extremely small and waiting 5 years for a scope should be quite safe. Having said that, "in this world nothing can be said to be certain, except death and taxes."

You might like to think of Barrett's as a friend there to protect you as in this article.
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chrisrob
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Quote chrisrob Replybullet Posted: 28 Aug 2017 at 8:51am
These comments are from an American gastroenterologist in a research paper published a couple of years ago, Stop scaring patients!:

"The vast majority — about 95% — of patients who develop esophageal adenocarcinoma do so outside of screening and surveillance, while most — again, about 95% — under surveillance do not develop esophageal cancer and die of other causes," Dr. Reid pointed out.

"We as clinicians must stop scaring our patients," Dr. Reid emphasized, noting that only about 5% of reflux patients are diagnosed with Barrett’s esophagus on endoscopy, and of those, only a minuscule proportion (0.3% - 0.7%) progress to cancer each year.

"Primary care doctors should have a fact sheet telling patients that if you have heartburn your chances of adenocarcinoma are very small, and that you can be screened or not screened, but there is no cure for Barrett's, and if you test positive you will be buying into repeated endoscopies for the rest of your life," Dr. Reid pointed out. This problem of overdiagnosis of indolent conditions while underdiagnosing fatal disease is a big issue in the medical world, he commented.

"In the meantime, physicians also have to recognize and stop using the word cancer because all it does is scare the patient," Dr. Reid added, concluding, "After you tell a patient that they have Barrett's and that only a very small minority develop cancer, just stop. Stop and acknowledge that you said a very scary word, 'cancer,' and make sure that the patient has heard the entire sentence."
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tracieann
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Quote tracieann Replybullet Posted: 28 Aug 2017 at 7:56pm
Yes Chrisrob it didnt help to find a mcmillan page about Barretts which scared the heavens out of me in a way its good we know when we have the correct info My consultant seems to favour AMERICAs way its not Barretts without metaplasia but Bsg say it is i get frustrated im on an open appt so if things alter i can book to see him thanks for the reassurance Chris its helped .By the way this website is great and so helpful

Edited by tracieann - 28 Aug 2017 at 7:58pm
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