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Mahmoud Barrie, M.D., Discusses Barrett’s Esophagus: An Update on New Developments

Tuesday, May 29th, 2012

By Mahmoud Barrie, M.D.

From ATLANTA Medicine, 2012, Gastroenterology, Vol. 82, No. 4

Barrett’s esophagus continues to be an evolving condition due to continued improvements in the areas of definition, pathophysiology, surveillance, diagnosis and therapeutic options.


The definition of Barrett’s esophagus in the United States has remained relatively unchanged as “salmon colored mucosa at the distal esophagus on endoscopy and evidence of intestinal metaplasia in the squamocolumnar junction on histology.” However, the British Society of Gastroenterology (BSG) defines Barrett’s esophagus as “an endoscopically apparent area above the esophagogastric junction that is suggestive of Barrett esophagus [salmon-colored mucosa], which is supported by the finding of columnar lined esophagus on histology,” suggesting that the presence of intestinal metaplasia is not a requirement. The BSG definition takes into account the absence of intestinal metaplasia due to sampling errors and the development of cancer in the absence of intestinal metaplasia. This definition, however, potentially increases the number of patients with the disease.


The mechanism of metaplasia in Barrett’s esophagus has not been well established. Mucosal injury from acid reflux is believed to be a prerequisite to its development, however, other factors — such as increased mucosal permeability — must be involved because not all patients with acid reflux develop Barrett’s esophagus.

Furthermore, a study by Fletcher et al. has revealed the formation of a pocket of highly acidic area at the gastroesophageal junction, which converts dietary nitrates to mutagenic Nitric oxide within the pocket, as a potential pathway to developing Barrett’s esophagus with dysplasia.

Surveillance and Risk Assessment

Despite the development of the Prague C and M (C=circumference and M=maximal length of Barrett’s, including tongues) classification of Barrett’s esophagus, only Prague M is used with any degree of consistency. A Barrett’s esophagus > 3 cm in length has been shown to increase the risk of development of dysplasia or adenocarcinoma.

Additionally, the question of who needs surveillance continues to evolve. White males older than age 50 with long-term dyspepsia were thought to be highest risk group. However, the new American Gastroenterological Association (AGA) guidelines suggest screening for Barrett’s esophagus in patients with multiple risk factors (such as being white, male and age 50 or older, and having elevated body mass index, diabetes, truncal obesity, chronic dyspepsia and/or hiatal hernia). There is no suggestion of the minimal number of risk factors required, but it is implied that screening is no longer limited to 50-year-old Caucasian males with chronic dyspepsia. The number of biopsies and the timing of surveillance endoscopy also have changed, perhaps to reflect the low incidence of adenocarcinoma (0.2% to 3.5% per year) and the cost of surveillance.

Most experts, including the AGA, recommend taking four quadrant biopsies every 2 cm in nondysplastic Barrett’s esophagus patients, but every 1 cm Barrett’s esophagus continues to be an evolving condition due to continued improvements in patients with known or suspected dysplasia. The endoscopic surveillance interval has been increased to every three to five years for nondysplastic Barrett’s esophagus patients and every six to 12 months for patients suspected of having dysplasia. For high-grade dysplasia without option of eradication, surveillance endoscopy every three months is recommended.

New Diagnostic Tools

Diagnosis of Barrett’s esophagus relies heavily on biopsy samples obtained from endoscopy. Thus, the ability to endoscopically identify Barrett’s esophagus with or without dysplasia will determine accuracy of the biopsies and, ultimately, the benefits of surveillance. New developments in enhanced imaging techniques — such as narrow band imaging (NBI), chemoendoscopy, confocal laser microscopy (CLM) and autofluorescence imaging (AFI) — are proving to be great assets.

NBI produces high-resolution images of the mucosa to help identify pre-malignant or malignant areas on the basis of irregular mucosal pattern. While CLM provides information at the cellular level during ongoing endoscopy, AFI uses blue light to detect fluorescence from biological tissue. However, the AGA guidelines do not currently support these techniques in the routine diagnosis of Barrett’s esophagus.

Therapeutic Options

The cornerstone for the treatment of Barrett’s esophagus is acid reflux therapy because mucosal injury from acid reflux is believed to be a prerequisite for the development of Barrett’s esophagus. It is important, however, to recognize that there are no prospective trials confirming that control of acid reflux prevents Barrett’s esophagus or cancer.

Multiple endoscopic techniques have developed for the management of Barrett’s esophagus with or without dysplasia. These include thermal techniques (multipolar electrocoagulation, argon plasma coagulation, heater probe, laser and radiofrequency ablation [RFA], and neodymium-doped ytrium aluminium garnet [ND:YAG]) and nonthermal techniques (photodynamic therapy, endoscopic mucosal resection [EMR] and cryotherapy). In a multicenter, randomized, sham-control trial by Shaheen et al, RFA was shown to produce complete eradication in 81% of patients with high-grade dysplasia and an overall complete eradication of intestinal metaplasia in 77.4% of patients — compared to 19% and 2.3%, respectively, in the control group.

Furthermore, eradication was observed in 90.5% of patient with low-grade dysplasia as compared to 22.7% in the control group. The risk for disease progression was also shown to be statistically lower in the RFA group compared to control. Therefore, RFA has emerged as the standard of care for flat lesions associated with Barrett’s esophagus with dysplasia and EMR is advocated for raised nodules.


Barrett’s esophagus is an evolving field with recent developments that are aimed at improving its diagnosis, surveillance and therapy. The incorporation of these new developments into daily practice will be gradual and deliberate with the ultimate goal of preventing esophageal adenocarcinoma due to Barrett’s esophagus.


Shaheen, N et al. Radiofrequency Ablation in Barrett’s Esophagus with Dysplasia. NEJM 2009 May 28;360(22):2277-88.

Playford, R. J. New British Society of Gastroenterology (BSG) guidelines for the diagnosis and management of Barrett’s esophagus. Gut 55, 442 (2006).

Chiu, P. W. et al. Esophageal pH exposure and epithelial cell differentiation. Dis.
Esophagus 22, 596–599 (2009).

Dvorak, K. et al. Expression of bile acid transporting proteins in Barrett’s esophagus and esophageal adenocarcinoma. Am. J. Gastroenterol. 104, 302–309 (2009).

Wang, C., Yuan, Y. & Hunt, R. H. Helicobacter pylori infection and Barrett’s esophagus: a systematic review and meta-analysis. Am. J. Gastroenterol. 104,
492–500 (2009).

Wang, K. K. & Sampliner, R. E. Updated guidelines 2008 for the diagnosis, surveillance and therapy of Barrett’s esophagus. Am. J. Gastroenterol. 103, 788–797 (2008).

Badreddine, R. J. & Wang, K. K. Barrett esophagus: An update. Nat. Rev. Gastroenterol. Hepatol. 7, 369–378 (2010).

Harrison, R. et al. Detection of intestinal metaplasia in Barrett’s esophagus: an observational comparator study suggests the need for a minimum of eight biopsies. Am. J. Gastroenterol. 102, 1154–1161 (2007).


Miriam Vos, M.D., Heads Research Team for NAFLD Study

Tuesday, May 29th, 2012

Suspected non-alcoholic fatty liver disease (NAFLD) is increasing in teens, affecting approximately 10 percent of the age group. Historically seen more often in adults, NAFLD can lead to liver damage, diabetes, hypertension and cancer.

In a study funded by the National Institutes of Health (NIH), researchers led by Miriam Vos, MD, MSPH, assistant professor of pediatrics at Emory University School of Medicine and a pediatric hepatologist at Children’s Healthcare of Atlanta, sought to determine whether rates of NAFLD seem high because people are studying them more closely or whether there really are more cases of teenagers with NAFLD.

The study was presented at Digestive Disease Week, an annual conference jointly sponsored by the American Association for the Study of Liver Diseases, the American Gastroenterological Association Institute, the American Society for Gastrointestinal Endoscopy and the Society for Surgery of the Alimentary Tract.

Investigators reviewed nationally representative data of more than 10,000 12- to 18-year-olds from the National Health and Examination Survey datasets, spanning 1988 to 2008. Suspected NAFLD was defined as overweight/obese (those with a body mass index greater than the 85th percentile) with elevated alanine aminotransferase (ALT), a blood test that is typically used to detect liver injury.

According to the study, the prevalence of NAFLD among U.S. teens grew from 3.6 percent to 9.9 percent, increasing at a rate faster than teen obesity during the same time.  In looking at cross-sectional data to explain the increase in prevalence of NAFLD, researchers found a link to increased NAFLD and waist circumference — the measure of the distance around the abdomen half way between the inferior margin in the last rib and the crest of the hip bone.

“We know that if a child is overweight, they are more likely to be overweight as an adult,” says Vos. “We know from national data that teens with fatty liver disease become adults with fatty liver disease, unless they improve their diet and lose a significant amount of weight.”

Vos noted that early intervention for NAFLD is essential, as is a coordinated plan of lifestyle modification and in some cases, medication.

“Adolescents may have an easier time losing weight compared to adults because they have been overweight for a shorter period of time, so there is less resistance to improving lifestyle habits like diet and exercise,” says Vos.  “My hope for the future is that we will have medications to help treat the most severe cases of NAFLD to help complement a healthy regimen of diet and physical activity.”

This summer, the -NIH-sponsored NASH Clinical Research Network will start a new clinical trial to research the treatment of NAFLD.

In the past, Vos and colleagues have studied the connection between diet and fat in the liver and increased cardiovascular risk. Data shows that cardiovascular disease is prevalent in adults with NAFLD, and multiple studies have shown that adolescents with NAFLD have markers that show increased risk for cardiovascular disease.


WellStar Physicians Perform Successful Percutaneous Aortic Valve Replacement Surgeries

Tuesday, May 29th, 2012

In a multidisciplinary approach to cardiac care, two heart surgeons and two interventional cardiologists recently performed two successful percutaneous aortic valve replacement surgeries at WellStar Kennestone Hospital. These procedures offer an alternative for patients who previously were unable to have traditional aortic valve replacement due to co-morbidities or other issues.

The team of physicians who participated in the two surgeries included interventional cardiologists Dr. Reitman and Amar Patel, M.D., and heart surgeons William A. Cooper, M.D. and Richard Myung, M.D. Echocardiographer Sarita Kansal, M.D. and cardiac anesthesiologist Matt Grabowski, M.D. also participated.

During these surgeries, the replacement valve, called the Edwards SAPIEN transcatheter heart valve and developed by Edwards Lifesciences, was passed through a hole in the groin and advanced up to the patient’s heart. It substitutes for a more invasive procedure in which the chest has to be opened in order to replace the valve.

According to Dr. Arthur Reitman, Medical Director for Cardiac Catheterization, and Dr. William Cooper, Medical Director for Cardiac Surgery for WellStar Health System, these collaborative efforts between cardiology and cardiac surgery are a new paradigm for innovative therapies and transformative care delivery for patients who might not qualify for traditional valve surgery and offer a patient-centered, comprehensive approach to structural heart disease.

Both patients had successful procedures.



CDC and NIH Find Heart Disease and Stroke Deaths Dropped Significantly for Diabetics

Tuesday, May 29th, 2012

Death rates for people with diabetes dropped substantially from 1997 to 2006, especially deaths related to heart disease and stroke, according to researchers at the Centers for Disease Control and Prevention and the National Institutes of Health.

Deaths from all causes declined by 23 percent, and deaths related to heart disease and stroke dropped by 40 percent, according to the study published recently in the journal Diabetes Care. Scientists evaluated 1997-2004 National Health Interview Survey data from nearly 250,000 adults who were linked to the National Death Index. Although adults with diabetes still are more likely to die younger than those who do not have the disease, the gap is narrowing.

Improved medical treatment for cardiovascular disease, better management of diabetes, and some healthy lifestyle changes contributed to the decline. People with diabetes were less likely to smoke and more likely to be physically active than in the past. Better control of high blood pressure and high cholesterol also may have contributed to improved health. However, obesity levels among people with diabetes continued to increase.

“Taking care of your heart through healthy lifestyle choices is making a difference, but Americans continue to die from a disease that can be prevented,” said Ann Albright, Ph.D., R.D., director of CDC’s Division of Diabetes Translation. “Although the cardiovascular disease death rate for people with diabetes has dropped, it is still twice as high as for adults without diabetes.”

Previous studies have found that rates of heart disease and stroke are declining for all U.S. adults. Those rates are dropping faster for people with diabetes compared to adults without diabetes. Recent CDC studies also have found declining rates of kidney failure, amputation of feet and legs, and hospitalization for heart disease and stroke among people with diabetes.

Because people with diabetes are living longer and the rate of new cases being diagnosed is increasing, scientists expect the total number of people with the disease will continue to rise. The number of Americans diagnosed with diabetes has more than tripled since 1980, primarily due to type 2 diabetes, which is closely linked to a rise in obesity, inactivity and older age. CDC estimates that 25.8 million Americans have diabetes, and 7 million of them do not know they have the disease.

CDC and its partners are working on a variety of initiatives to prevent type 2 diabetes and to reduce its complications. CDC leads the National Diabetes Prevention Program, a public-private partnership designed to bring evidence-based programs for preventing type 2 diabetes to communities. The program supports establishing a network of lifestyle-change classes for overweight or obese people at high risk of developing type 2 diabetes.

“Diabetes carries significant personal and financial costs for individuals, their families, and the health care systems that treat them,” said Edward W. Gregg, Ph.D., the study’s lead author and chief of epidemiology and statistics in CDC’s Division of Diabetes Translation. “As the number of people with diabetes increases, it will be more important than ever to manage the disease to reduce complications and premature deaths.”

Controlling levels of blood sugar (glucose), cholesterol and blood pressure helps people with diabetes reduce the chance of developing serious complications, including heart disease, stroke, blindness and kidney disease.

In 2001, the National Diabetes Education Program (NDEP), a joint effort of CDC and NIH with the support of more than 200 partners, developed a campaign to raise awareness of the link between diabetes and heart disease and reinforce the importance of a comprehensive diabetes care plan that focuses on the ABCs of diabetes – A1C (a measure of blood glucose control over a two- to three-month period), Blood pressure and Cholesterol.

Last year CDC and the Centers for Medicare & Medicaid Services launched Million Hearts, an initiative to prevent 1 million heart attacks and strokes over the next five years. The initiative focuses on two main goals: empowering Americans to make healthy choices and improving care for people, focusing on aspirin for people at risk, blood pressure control, cholesterol management and smoking cessation. More than 2 million heart attacks and strokes occur every year, and treatment for these conditions and other vascular diseases account for about 1 of every 6 health care dollars. Up to 20 percent of deaths from heart attack and 13 percent of deaths from stroke are attributable to diabetes or prediabetes.

Diabetes was the seventh leading cause of death in 2009 and is the leading cause of new cases of kidney failure, blindness among adults younger than 75, and amputation of feet and legs not related to injury. People with diagnosed diabetes have medical costs that are more than twice as high as for people without the disease. The total costs of diabetes are an estimated $174 billion annually, including $116 billion in direct medical costs.


Neurosurgeon Kevin Hsieh, M.D., Joins Piedmont Physicians Group

Monday, May 28th, 2012

Neurosurgeon Kevin Hsieh, M.D., who specializes in spine surgery and is trained in many of the newest techniques in minimally invasive surgery, recently joined the team at Piedmont Physicians Neurosurgery.

Prior to joining Piedmont Physicians Neurosurgery, Dr. Hsieh practiced at Peachtree Neurosurgery and traveled around the world to provide care for underserved populations. He also has spent significant research time reporting surgical outcomes of the largest pediatric series of craniopharyngiomas and studied the use of Gamma Knife® radiosurgery in brain metastases of melanoma.

Dr. Hsieh earned a Bachelor of Science in molecular cell biology with an emphasis in neurobiology from the University of California, Berkeley and received his medical degree from Vanderbilt University, where he was involved in a research project on functional MRI and localization of brain function. Dr. Hsieh then went on to complete his neurosurgery residency at New York University Hospitals and was chief resident at Bellevue Hospital and at the VA Hospital in Manhattan.



Piedmont Heart Institute Receives Grant for Heart Valve Center

Thursday, May 24th, 2012

The Piedmont Heart Institute has received a $20 million grant from the Marcus Foundation to establish the nation’s first heart valve reference center at Piedmont Hospital. As a regional reference center, the Marcus Heart Valve Center will be a one-stop shop for patients with heart valve problems as well as for physicians wanting to learn the latest advancements in treatment for these complex patients and increase access to care.

“We take this charge very seriously,” said Charles Brown, M.D., interventional cardiologist and chief medical officer, Piedmont Heart Institute. “We will build a valve center worthy of the Marcus name.”

The Marcus Foundation, dedicated to Jewish causes, children, medical research, free enterprise and the community, has funded many enhancements to healthcare in Atlanta including neurosciences at Grady Health System and The Marcus Autism Center at Children’s Healthcare of Atlanta.

The Marcus Heart Valve Center  will be the nation’s first comprehensive valve center for care, training and research regardless of the valve in which the damage occurs – aortic, mitral, pulmonary, and tricuspid valve — or the reason for it — congenital or acquired. It is expected to draw more renowned surgeons and other specialists.

According to the American Heart Association, mitral valve regurgitation is the most common type of heart valve insufficiency in the United States. Because prevalence increases with age, the growing population of people over the age of 65 will create an increased demand in an area that is already undertreated according to well-respected cardiology journals.

“The skill and experience of the surgeon are probably the most important determinants of whether repair or replacement surgery is performed,” Dr. Brown said. “Repair is the treatment of choice when surgical skill and expertise are available. Appropriate treatment results in better outcomes and quality of life for patients.”



MAA Board Meeting

Monday, May 21st, 2012

May 21, 2012. For more information, visit Medical Association of Atlanta


NFMGMA May Educational Session

Wednesday, May 16th, 2012

May 16, 2012, Alpharetta. For more information, visit North Fulton Medical Group Management Association


WellStar’s Smyrna Pediatrics Welcomes Aixa Silvera-Schwartz, M.D.

Monday, May 14th, 2012

Aixa Silvera-Schwartz, M.D., has joined WellStar Medical Group, Smyrna Pediatrics.

Dr. Silvera-Schwartz received her medical degree from the University of Panama School of Medicine in Panama City, Panama. She completed an internship at the Hospital Caja del Seguro Social and the Rafael Hernandez Hospital in the Republic of Panama. Following her internship, she started a residency at the Hospital Caja del Seguro Social in the Republic of Panama and completed her residency at the Woodhull Medical and Mental Health Center in Brooklyn, New York.

Dr. Silvera-Schwartz is board certified in pediatrics. Her specialties include early intervention and prevention in newborns to five years old, obesity and asthma.

Prior to joining WellStar Smyrna Pediatrics, Dr. Silvera-Schwartz worked as a lead pediatrician for the ambulatory department at Grady Health System. She is a fellow of the American Academy of Pediatrics and a chair member of the Georgia American Academy of Pediatrics for Early Education and Child Care.


Ram Subramanian, MD, Says There is Hope for Acute Liver Failure Patients

Monday, May 14th, 2012

For patients in acute liver failure, time is precious. In many cases, a patient’s only hope is a liver transplant, but the wait for a viable — and matching — organ can be too long.

The Emory Transplant Center now offers Molecular Adsorbents Recirculating System (MARS), a liver dialysis system approved by the U.S. Food and Drug Administration (FDA) to treat select patients with acute liver failure due to drugs or toxins. Acute liver failure often results from drug overdose or idiosyncratic medication reactions. The most common cause of acute liver failure is acetaminophen overdose.

“We have long had kidney dialysis to stabilize patients in renal failure, but until now, we have not had a corresponding method of treatment for patients in acute liver failure,” says transplant hepatologist and intensivist Ram Subramanian, MD, assistant professor at Emory University School of Medicine. “ MARS is a potential game changer for patients who either don’t qualify for transplant or who don’t have the time that is critical to wait for a transplant.”

Patients in acute liver failure are unable to clear certain toxins from their systems, so the MARS system does the work for them by drawing blood from patients and cleansing it with solution containing albumin. Albumin is produced by healthy livers and binds to certain medications and other bodily substances to transports them throughout the body. It also binds toxins, protecting the body from their toxic effects. The cleansed blood is returned to the patient’s circulatory system to attract more toxins.

While MARS currently is FDA approved only for treatment of acute liver failure, MARS has been used successfully in clinical trials to treat forms of chronic liver illness.

“Several studies in Europe have demonstrated that MARS is effective in treating chronic liver failure as well,” says Subramanian. “My hope is that it becomes another tool for us in offering hope to patients who are dealing with all kinds of liver failure.”



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