1. Case 519: 63 y/o man with long standing heart burn and progressive dysphagia

2. A 63 year-old man complains of progressive dysphagia for two months. He has difficulty swallowing solids. He has suffered from daily “heartburn” symptoms for most of his adult life and has been prescribed ranitidine by his physician for many years. He hasn’t drunk alcohol for five or six years. He stopped because of “gastric problems”. He stopped smoking about the same time.

3. 160 pound male in no acute distress. P: 80/min, BP: 120/80, resp: 16/min HEENT: normal. Neck:supple, no masses. Chest:clear to A&P, Heart:regular, no murmurs Abdomen: slight epigastric tenderness, no rigidity, no masses or organomegaly. Bowel sounds normal. No hernia. Male genital: normal, Rectal: prostate soft and nodular, no masses

5. Biopsy of lower esophagus of a patient with classic reflux symptoms. Note inflammatory cells in the mucosa

6. Higher power. Note acute inflammatory cells (neutrophils and eosinophils) in squamous mucosa

7. Surgical resection specimen of Barrett’s esophagus. The reddish areas represent areas of glandular metaplasia

8. Microscopic view of an area of glandular metaplasia with intestinal-like cells (globlet cells). This area should be squamous mucosa

9. Same area stained by Alcian blue for mucus. This is intestinal metaplasia

10. Biopsy of this patient’s lesion in the lower esophagus-moderately differentiated adenocarcinoma

11. The surgical resection specimen-a large adenocarcinoma arising in the lower esophagus in an area of Barrett’s metaplasia esophagus stomach

12. Surgical resection specimens of a classic squamous cell carcinoma in the mid-portion of the esophagus. This is the type associated with heavy tobacco and alcohol use