Assessment Module Layout Questions Correct Answers Incorrect Answers Critique/Rationale Link to Didactic Content for Additional Study Link to Additional Study Materials What is the ACC doing and what is the ACG doing related to assessment? Revisit Initial Questions & Answer Correctly Other Enduring Materials (CME) Digitally Captured Live Presentations Post to a Discussion Forum Materials Outside of AGA Including TheGut.org Other Critique/Rationale Link to Additional Study Materials Application to Practice Evaluation

Question answered correctly A 52 year old Caucasian male is referred to you for heartburn. He has a 20 yr history of heartburn with intermittent symptoms while on once a day PPI therapy. He denies dysphagia, nausea or vomiting. His physical examination is notable for a BMI of 40, but his physical examination and laboratory studies are otherwise unremarkable. EGD shows the following in the distal esophagus: Endoscopic biopsies are likely to show: A: Normal gastric epithelium. B: Intestinal metaplasia. C: Erosive esophagitis. D: Squamous cell carcinoma. E: Adenocarcinoma.

Critique/Rationale: Barrett’s esophagus is found in approximately 6 to 12% of patients undergoing endoscopy for symptoms of GERD and in 1% or less of unselected patient populations undergoing endoscopy. The prevalence of long-segment Barrett’s esophagus (3 cm or more of interstitial metaplasia) is approximately 5%, whereas that of short-segment Barrett’s esophagus (less than 3 cm of interstitial metaplasia) is approximately 6 to 12% in patients undergoing endoscopy in a variety of settings. Autopsy data suggest that the majority of cases of Barrett’s esophagus go undetected in the general population. This may be due to the observation that esophageal sensitivity to acid perfusion is impaired in these patients. Furthermore, only approximately 5% of patients with esophageal adenocarcinoma have an antecedent diagnosis of Barrett’s esophagus.

Correct Answers will Link to Additional Study Materials AGA Institute Cases Online A Woman with Worsening GERD and Barrett’s Esophagus TheGut.org High Stakes and High Risk: Improving the Odds in Barrett's Esophagus, Colorectal Cancer and NSAID-Induced Complications PubMed The development and validation of an endoscopic grading system for Barrett's esophagus: the Prague C & M criteria Practice guidelines ASGE: Role of Endoscopy in The Management of Barrett's Esophagus SSAT: Patient Care Guidelines Management of Barrett's Esophagus

Additional Links for Reference and Study AGA Institute Position Statement and Technical Review Role of the Gastroenterologist in the Management of Esophageal Carcinoma GI Core Curriculum Training in Acid-Peptic Disease (chapter 1, third edition, May 2007) Future Trends Committee Endoscopic advances (October 2006)

Question answered incorrectly A 52 year old Caucasian male is referred to you for heartburn. He has a 20 yr history of heartburn with intermittent symptoms while on once a day PPI therapy. He denies dysphagia, nausea or vomiting. His physical examination is notable for a BMI of 40, but his physical examination and laboratory studies are otherwise remarkable. EGD shows the following in the distal esophagus: Endoscopic biopsies are likely to show: A: Normal gastric epithelium. B: Intestinal metaplasia. C: Erosive esophagitis. D: Squamous cell carcinoma. E: Adenocarcinoma.

Incorrect Answers will Link to Didactic Content for Additional Study Barrett’s esophagus is a complication of gastroesophageal reflux disease. Endoscopically, this lesion is recognized by displacement of the squamocolumnar junction proximal to the gastroesophageal junction. Histologically, it is characterized by metaplastic transformation of the esophageal squamous epithelium to a specialized columnar intestinal metaplastic epithelium with acid mucin-containing goblet cells Return to question for retest:

Revisit Initial Question & Answer Correctly Question A 52 year old Caucasian male is referred to you for heartburn. He has a 20 yr history of heartburn with intermittent symptoms while on once a day PPI therapy. He denies dysphagia, nausea or vomiting. His physical examination is notable for a BMI of 40, but his physical examination and laboratory studies are otherwise unremarkable. EGD shows the following in the distal esophagus: Endoscopic biopsies are likely to show: A: Normal gastric epithelium. B: Intestinal metaplasia. C: Erosive esophagitis. D: Squamous cell carcinoma. E: Adenocarcinoma.

Critique/Rationale: Barrett’s esophagus is found in approximately 6 to 12% of patients undergoing endoscopy for symptoms of GERD and in 1% or less of unselected patient populations undergoing endoscopy. The prevalence of long-segment Barrett’s esophagus (3 cm or more of interstitial metaplasia) is approximately 5%, whereas that of short-segment Barrett’s esophagus (less than 3 cm of interstitial metaplasia) is approximately 6 to 12% in patients undergoing endoscopy in a variety of settings. Autopsy data suggest that the majority of cases of Barrett’s esophagus go undetected in the general population. This may be due to the observation that esophageal sensitivity to acid perfusion is impaired in these patients. Furthermore, only approximately 5% of patients with esophageal adenocarcinoma have an antecedent diagnosis of Barrett’s esophagus.

Correct Answers will Link to Additional Study Materials AGA Institute Cases Online A Woman with Worsening GERD and Barrett’s Esophagus TheGut.org High Stakes and High Risk: Improving the Odds in Barrett's Esophagus, Colorectal Cancer and NSAID-Induced Complications PubMed The development and validation of an endoscopic grading system for Barrett's esophagus: the Prague C & M criteria Practice guidelines ASGE: Role of Endoscopy in The Management of Barrett's Esophagus SSAT: Patient Care Guidelines Management of Barrett's Esophagus

Additional Links for Reference and Study AGA Institute Position Statement and Technical Review Role of the Gastroenterologist in the Management of Esophageal Carcinoma GI Core Curriculum Training in Acid-Peptic Disease (chapter 1, third edition, May 2007) Future Trends Committee Endoscopic advances (October 2006)

Application to Practice (didactic) The epidemiology of Barrett's esophagus is incompletely described. Published studies indicate it is more prevalent in older, white males, a pattern that mirrors that of esophageal adenocarcinoma (EAC). Emerging data suggests that Barrett's may be as prevalent in Hispanics as whites, and that rates among women and other minority groups are increasing. In patients with esophageal reflux disease, those with Barrett's are more likely to report the onset of GERD at an early age, have increased duration of symptoms, increased severity of nocturnal symptoms and more GERD-related complications such as esophagitis, ulceration, stricture and bleeding. The increased risk of Barrett's in this type of patient may be great, with some studies citing a 6.4 fold increase in those with symptoms greater than 10 years. Thus, symptoms of Barrett's are indistinguishable from symptoms of GERD without Barrett's complications. Further, many with Barrett's have no symptoms at all. Other factors have also emerged as potentially related to the development of EAC, including tobacco use, diet low in fruits and vegetables, and increased body mass index (BMI). Interestingly, evidence suggests that use of aspirin/NSAIDs may be associated with decreased risks of EAC.

AGA CME Café (2005): Barrett's Esophagus and Adenocarcinoma

AGA Institute Discussion Forum

AGA Institute Discussion Forum “How frequently do you screen your at risk patients? Every two or three years?”

Practice Improvement Modules (PIMs) Option for members to build their own PIMs around Barrett’s Esophagus: How does your practice track patients with interstitial metaplasia, interstitial metaplasia with low-grade and high-grade metaplasia? What performance measures will you use to prospectively track how you manage these patients? Etc. [PIMs satisfy specific point requirements for MOC and are eligible for CME credit]

Assess learner’s experience Helpful, not helpful in making clinical decisions with your patients? How would you rank the utility of these educational materials on this topic? Are there any revisions you would you make to this educational material? [Offer the member an opportunity to post their thoughts to an AGA Institute discussion forum]

Back office functions: Log responses & route them To the member’s personal learning portfolio (populates CME credit and points toward MOC) To an activity database that aggregates member feedback Continuous needs assessment data Continuous member assessment of activity effectiveness (dynamic ranking of materials when members search) Determine when educational activities need revision, content accuracy or teaching effectiveness may have eroded

Benefits Real time assessment and modification of the questions and critiques Updates quicker based on learner responses and changes in the science Granular: substantive learning can be done in 10-15 minute increments Ubiquitously available from a desktop PC or PDA Paperless production will control costs

The Next Question Four modules, thematically related, in sequence, and by design. The plan: “Think big, start small, scale fast.” The concept: “Aesthetic rigor: elegance, economy and formal coherence.”

National Medical Society Mission of a National Medical Society Support Research Enterprise (Basic Science & Clinical) Encourage Curiosity Member Personal Learning Portfolio Information Disseminated Build a Professional Community Patient Care is Delivered

Instructional Designer Now Hiring! Instructional Designer Contact: Charles Willis (301) 941-2604 cwillis@gastro.org

Thanks to: JB McGee, MD Geoff Braden, MD Jay Kuemmerle, MD Ashley Lombard Carrie Smith Kwesi Agyeman