Question ： A 62-year-old man with a history of mild heartburn undergoes an upper gastrointestinal endoscopy for evaluation of iron-deficiency anemia. He has a history of coronary artery disease, hypertension, diabetes, and obesity. His current medications include aspirin, enalapril, metformin, and glyburide. He also takes naproxen twice weekly for joint pain. Endoscopy reveals erosive esophagitis (Los Angeles Grade C) and 3 cm of salmon-colored mucosa, proximal to the gastroesophageal junction. Biopsies are obtained and demonstrate evidence of chronic inflammation and indefinite dysplasia. What is the most appropriate next step in management?
A. Endoscopic mucosal resection
B. Endoscopic ultrasound
C. Naproxen discontinuation
D. Proton pump inhibitor
E. Radiofrequency ablation
参考翻译：一名62岁男性有轻度烧心史，做上消化道内镜以评估缺血性贫血。他既往有冠心病、高血压、糖尿病和肥胖史、他经常服用的药物有阿司匹林，依那普利，二甲双胍和格列本脲。他还因为关节疼痛每周二次服用萘普生。内镜显示为糜烂性食管炎（LOS -C）和3cm橙红色的黏膜，从近端到胃食管交界处。病理活检提示慢性炎症和不确定的异型增生。接下来哪一步是最合适的处理方法？
A．内镜下黏膜切除
B．超声内镜
C．停用萘普生
D．质子泵*制剂抑**
E．射频消融治疗
CORRECT ANSWER: D RATIONALE
In the setting of esophagitis and chronic inflammation, the diagnosis of dysplasia can be difficult to ascertain, often leading to a pathology read showing indefinite dysplasia. For someone who is not on a proton pump inhibitor, the next best step would be to start a proton pump inhibitor and repeat the upper gastrointestinal endoscopy with biopsy in 8 to 12 weeks to confirm dysplasia versus inflammation artifact. Endoscopic mucosal resection can be used to resect raised lesions demonstrating dysplasia or early esophageal malignancy without deep submucosal invasion, neither of which is present in this case. Endoscopic ultrasound is used to stage esophageal cancer and is not necessary in the setting of dysplasia or possible dysplasia. Rare naproxen use is not likely causing the esophagitis in this case and would not need to be discontinued. Although radiofrequency ablation is appropriate for flat Barrett’s esophagus with dysplasia, it is unclear if the biopsy shows dysplasia or if this is an overcall in the setting of significant inflammation. REFERENCE Shaheen NJ, Falk GW, Iyer PG, Gerson LB. ACG Clinical Guideline: Diagnosis and Management of Barrett’s Esophagus. American Journal of Gas troenterology. 2016;111(1):30-50. doi:10.1038/ ajg.2015.322[1]
正确答案：D，理由如下：
在食管炎和慢性炎症的患者中，异型增生的诊断往往很难确定，导致病理科医生在诊断报告上显示为不确定性异型增生。如果该患者尚未使用PPI，下一步是开始使用PPI，在治疗8-12周内重复内镜检查和病理活检以证实病理活检是异型增生还是慢性炎症的假象。内镜下黏膜摘除可以用于切除隆起病灶提示异型增生或早期食管恶性肿瘤但未有深部黏膜下侵及的病灶，但这两种情况在本例患者均未出现。超声内镜可以用于食管癌的分期，对于确定异型增生或可能的异型增生并无必要。偶尔萘普生应用不大可能引起食管炎因而没有必要停用药物。虽然射频消融可以用于平坦巴雷特食管伴异型增生，但是该例病例的活检病理诊断究竟是异型增生还是炎症情况下的假象尚不明确，因此不是最佳选项。
