Q: Barrett's oesophagus
A patient presents with Barrett's oesophagus, with a segment length of 3cm. Does he need to take proton pump inhibitors (PPIs) for life, even if he becomes asymptomatic after one year, or can this be taken on an 'as-required' basis for six to eight weeks at a time when he becomes symptomatic?
The short answer is that patients with Barrett's oesophagus should remain on lifelong PPI therapy.
Barrett's oesophagus will require lifelong treatment with PPIs
The reason for this is that there is evidence that continuous PPI therapy prevents the progression of dysplasia from mild to severe and therefore reduces the risk of a carcinoma developing. Such treatment may also initiate regression of Barrett's oesophagus.
If the patient is unwilling to remain on lifelong PPIs or his symptoms are not well controlled, consider refferal for a laparoscopic Nissen's fundoplication, as this also reduces the risk of progression of dysplasia and may initiate regression of short-segment Barrett's oesophagus.
Other possible treatments include photodynamic therapy, radiofrequency ablation and submucosal resection, all of which are relatively unproven.
You should consider referring the patient for regular endoscopic surveillance of his Barrett's oesophagus as there is evidence that such a strategy leads to the earlier detection of oesophageal cancers and improved survival.
Mr Dugal Heath, consultant gastroenterologist and laparoscopic surgeon, The London Clinic
Q: Hepatitis A vaccination immunity period
If someone has been given the two hepatitis A injections, as recommended, what immunity does this confer and when would they need a booster? I remember reading somewhere that this may confer immunity for 25 years. Is this correct?
Provided the patient is aged one year or over, is immunocompetent and has received the first and second dose of a licensed hepatitis A monovalent vaccine within the recommended intervals, immunity should be of long-term duration.
The Joint Committee on Vaccination and Immunisation has accepted protection to be of at least 20 years' duration. It is possible that such immunity is lifelong but, for now, we should advise patients that protection will last at least 20 years.
Dr George Kassianos is a GP in Berkshire and spokesman for immunisation at the RCGP and the British Travel Health Association.