Barrett's Esophagus
By gi health
The name may not be familiar to you, but thousands of Americans are diagnosed each year
with Barrett's Esophagus, a precancerous condition often associated with severe heartburn.
If you have been told you have Barrett's Esophagus, this brochure may help answer some of
your questions. If you have additional questions, ask your doctor.
What Is Barrett's Esophagus?
To help you digest your food, your stomach produces large amounts of hydrochloric acid
every day. This powerful acid can liquefy a piece of meat in a short time, but amazingly
does not damage your stomach itself. This is because your stomach has a special lining to
protect itself from the effects of the acid. However, your esophagus, or food pipe, has no
protective lining. Instead, there is a one-way "check valve" located at the bottom of the
esophagus that normally prevents backflow of stomach acid.
Called the Lower Esophageal Sphincter, this valve opens to allow food to enter the stomach
and then quickly closes to prevent the corrosive stomach acid from damaging your delicate
esophageal lining. If this valve gets weak, however, acid from the stomach is allowed to
come up into the esophagus causing red erosions, like scrapes of the skin on the normally
pinkish lining of the esophagus. This condition is called Gastroesophageal Reflux Disease, or
GERD. If the condition is not properly treated, the erosions will continue and over time a
permanent red lining may develop. The cells in this lining resemble those of the small
intestine more closely than the normal esophagus, and are termed "intestinal metaplasia."
This is the hallmark of Barrett's Esophagus - named after British surgeon, Norman Barrett,
who first identified this ailment in 1950. So, Barrett's is a condition where the pink lining of
the lower esophagus is damaged by years of uncontrolled acid reflux and then the damaged
area is replaced by a new abnormal red lining which "creeps up" into the lower esophagus.
How Common Is Barrett's Esophagus?
Twenty percent or more of adults have chronic GERD and of these 10% to 15% will have
Barrett's Esophagus, meaning that 1% to 2% of the American adult population potentially
has this premalignant condition. Men and women with chronic severe reflux have over a
50% chance of having Barrett's Esophagus.
Why Is Barrett's Important?
Overall, only about 0.5% per year of individuals with Barrett's Esophagus will go on to
develop esophageal cancer, but this rate is 40 times higher than normal. Considered an
oddity until the 1970's, the incidence of esophageal cancer has increased rapidly in the past
30 years and is now the fastest rising cancer in adults. Esophageal cancer seems to affect
men much more than women.
What are the Symptoms?
There really are no symptoms of Barrett's itself, but most patients have a history of long
standing acid reflux and complain of heartburn or indigestion, occurring at least two times a
week. Other symptoms may include: difficulty swallowing food, waking up at night because
of heartburn pains, persistent unexplained cough, or hoarseness. If you have these
symptoms, you should be checked for Barrett's. Unfortunately, some patients with Barrett's
have very little heartburn and no warning, even though they have significant damage.
How does My Doctor Know?
Barrett's cannot be diagnosed by blood tests or x-rays. Screening for Barrett's Esophagus
requires a gastroscopy, or "scope" examination to directly visualize the lower esophagus
and determine if there is any damage. This is painlessly done under light sedation. During
this exam, samples can also be taken to confirm the presence of Barrett's and to check for
precancerous changes, or dysplasia.
Why Bother Checking For Barrett's?
Anytime a cell line changes in the body, there is the potential for cancerous changes. The
challenge is to identify patients with Barrett's Esophagus before they develop cancer. If you
have Barrett's and biopsies show precancerous cells, new techniques are available to
monitor and help halt the process. Progression to cancer can often be prevented. However,
it's estimated that only 5 percent of people with Barrett's are now diagnosed.
What Treatment Is Available?
Once Barrett's Esophagus is identified, doctors have several treatment options available.
The first goal is to stop acid reflux and prevent further damage from occurring. This can
usually be accomplished with daily doses of medications such as Prilosec, Prevacid, Aciphex,
Protonix, and Nexium which markedly reduce your production of stomach acid. Treatment
relieves symptoms and may also reduce the risk of forming a stricture, a ring of scar tissue
which may cause problems swallowing.
You should know that successful treatment of the acid reflux does not cure the Barrett's.
Even if symptoms are well controlled, the cancer risk remains and periodic scope
examinations must be continued. Usually these are done every one to two years.
What If Dysplasia Is Found?
Biopsies taken during the scope test are sent for microscopic analysis by a trained doctor
called a Pathologist. The main thing we ask the Pathologist to look for is "dysplasia."
Dysplasia is a precancerous change (not cancer yet) which usually occurs before cancer
ever develops. It can be thought of as an early warning signal and is often classified either
as low grade or high grade dysplasia.
Low grade dysplasia is seen most often and is less cause for concern. In this instance, reflux
must be controlled and surveillance may need to be more frequent but there is no need for
radical change in therapy. Over time, dysplasia may progress from low grade to high grade,
then sometimes to cancer.
If high grade dysplasia is found, the risk of cancer is much greater. Patients with high grade
dysplasia need to be rescoped at more frequent intervals and additional biopsies obtained.
If high grade dysplasia persists, there is a high risk of progression to cancer. In this
circumstance, more aggressive treatment is needed. This involves surgery to remove part of
the esophagus which contains the abnormal area of Barrett's, even if a definite cancer is not
found. The whole idea is to do something before cancer develops.
How About Surgery?
There are two types of surgery performed in cases of Barrett's. If no dysplasia is present
and symptoms of acid reflux do not respond to intensive medical therapy, surgery may be
necessary to retighten the loosened lower esophageal sphincter, thus preventing further
acid damage. This operation does not remove the area of Barrett's which still must be
periodically rebiopsied. In the past, this procedure required open surgery with a full incision
and a prolonged recovery period. Newer "band-aid" techniques now allow a much simpler
procedure with several mini-incisions and a shortened recovery period.
If the condition is identified at a later stage, patients may require surgery to actually
remove part of the esophagus and pull the stomach upward to the remaining portion. This is
a more radical operation, but totally removes the area of Barrett's.
Are There Any Alternatives?
Photodynamic Therapy (PDT)
In this procedure, special light-activated dyes are given by vein which makes the area of
Barrett's especially sensitive to laser light. This allows selective destruction of the area of
Barrett's lining without damaging the entire wall of the esophagus. The area becomes
ulcerated and is treated with medication. In most cases, when the ulcer heals, it is replaced
by the normal pale esophagus lining and not the abnormal stomach lining.
Thermal Ablative Therapy
Other forms of ablation are being studied. One which holds promise is the use of a heater
probe. This device is passed down through the center channel of a gastroscope. The tip has
a computer controlled heating device that "cooks" the tissue it contacts. This device has
been used for many years in the treatment of bleeding ulcers and is now being tested in
patients with Barrett's. One great concern with these new destructive techniques is that not
all of the Barrett's cells will be destroyed and some may hide under the newly formed lining
with a potential for future cancer. Surveillance should be continued after treatment.
Endoscopic Mucosal Resection (EMR)
Another new procedure might be useful when the Barrett's changes only involve a short
segment (less than 2 cm). Using the gastroscope and a suction device, the inner layer of a
portion of the esophagus is cut away. This may allow normal cells to replace the Barrett's
tissue. Early reports are encouraging.
Chemoprevention
This refers to the exciting possibility that some medications taken by mouth may reduce the
chances of Barrett's cells becoming dysplastic and developing into esophageal cancer. This
research is very preliminary, but suggests that a daily 25,000 unit dose of the vitamin betacarotene may be helpful. This dose is considered safe for long term use. In addition, animal
studies suggest that aspirin and other arthritis drugs such as Clinoril, Vioxx, and Celebrex
may offer some protection. For example, in one study the risk of cancer was reduced 79%
by Clinoril administration. All of these drugs can sometimes cause stomach ulcers, but these
are effectively prevented by the acid reducing medication that is already being prescribed.
This research is very exciting and suggests that chemoprevention may be a useful
treatment option for the prevention of cancer.
Summary
Barrett's Esophagus is a precancerous condition in which an abnormal lining grows up into
the lower esophagus. This is usually a consequence of long-standing poorly controlled acid
reflux. Barrett's tissue does not belong there and for some reason increases the risk of
cancer. Most often, the development of this type of cancer is preceded by findings of
dysplasia on biopsy. Currently, screening by periodic "scope" examinations is the only
available way to determine if dysplasia is present.
If you have Barrett's Esophagus, you will require periodic monitoring by your physician.
Follow your doctor's advice about how best to control your acid reflux. This may include
lifestyle changes, medication, and/or surgery. The goal should be complete control of
heartburn. Keep your appointments for regular endoscopy exams and biopsies to check for
dysplasia.
Be reassured that most patients with Barrett's do not go on to develop cancer of the
esophagus. The overall risk is low. By working with your doctor and having periodic
examinations, you can best control the symptoms of acid reflux and help reduce your
personal risk of esophageal cancer.