Counselling for Barrett's Esophagus: A Comprehensive Guide to PLAB 2 Success

Summary:

This case focuses on counseling a patient with long-standing GERD (gastroesophageal reflux disease) who has developed Barrett’s esophagus, a condition requiring clear communication about diagnosis, lifestyle modifications, and management strategies to mitigate risks.

Key Points:

Data Gathering:

• Patient History:

  • GERD symptoms for five years, managed with omeprazole without improvement.

  • Persistent regurgitation, nocturnal symptoms, and chest pain.

  • Lifestyle details: pizza delivery job with high junk food consumption, smoking, and alcohol use.

  • Discomfort with prior endoscopy.

• Disease Understanding:

  • Lack of patient understanding regarding metaplasia and its implications.

  • Patient concern about the potential for cancer development.

Diagnosis:

• Findings:

  • Barrett’s esophagus with metaplasia and no dysplasia or neoplasia.

  • Persistent GERD symptoms suggest inadequate control.

Management:

• Medical:

  • Adjust omeprazole dose or switch to an alternative PPI.

  • Regular surveillance endoscopies every 3 years for monitoring progression.

• Lifestyle:

  • Counseling on dietary improvements, reducing junk food, and incorporating healthy options.

  • Recommendations to quit smoking and limit alcohol intake.

  • Importance of weight management due to borderline high BMI.

• Safety Netting:

  • Clear explanation of potential complications like esophageal cancer.

  • Provision of educational leaflets about Barrett’s esophagus and GERD.

Examination:

• Physical Examination:

  • Focus on GI system, neck palpation, oral cavity, and vitals like BMI, pulse, and blood pressure.

  • Documentation of findings to rule out immediate complications.

Important Considerations:

• Barrett’s esophagus increases the risk of esophageal cancer, necessitating regular 3-5 years monitoring.

• Address patient concerns about endoscopy discomfort; offer solutions like sedation during the procedure.

• Clear explanations about the reversible nature of lifestyle-induced GERD and potential long-term outcomes.

Diagnostic Approach:

1. History Taking:

   • Detailed exploration of GERD onset, symptom severity, and treatment compliance.

   • Enquire about nocturnal symptoms, dietary habits, and alcohol/smoking history.

2. Examination:

   • Check for physical signs of chronic GERD or complications.

3. Investigations:

   • Regular endoscopies for Barrett’s surveillance.

   • Additional tests if indicated by physical exam findings.

Management:

Step 1: Adjust Medications

• Review PPI therapy efficacy and optimize dosage.

• Consider adjunctive treatments like H2 blockers if needed.

Step 2: Lifestyle Modifications

• Encourage dietary changes to reduce acid reflux triggers (spicy foods, caffeine, alcohol).

• Promote smoking cessation and structured exercise plans.

Step 3: Monitoring

• Recommend follow-up endoscopies every 3 years.

• Safety-netting for worsening symptoms like dysphagia or weight loss.

Step 4: Patient Support

• Address concerns about endoscopy with empathy.

• Reassure the patient about available options to manage discomfort during procedures.

Communication Skills:

• Use simple, non-medical language when explaining terms like "metaplasia" and "neoplasia."

• Elicit and address patient concerns empathetically.

• Provide tailored lifestyle advice aligned with the patient’s routine (e.g., realistic dietary suggestions for a pizza delivery worker).

Ethical Considerations:

• Respect the patient’s autonomy regarding their discomfort with endoscopies while emphasizing the medical necessity.

• Maintain a patient-centered approach to avoid coercion.

Additional Resources:

• GMC Guidance: Standards for communication and patient support​.

• Educational Material: Leaflets about GERD and Barrett’s Esophagus.

• PLAB 2 Preparation: Examiner’s tips for counseling and communication​​.