Barrett's Esophagus

What is Barrett's esophagus?

 

The muscular layers of the esophagus — the hollow tube that carries food and liquids from the mouth to the stomach — are normally pinched together at both the upper and lower ends by muscles called sphincters. When a person swallows, the sphincters relax to allow food or drink to pass from the mouth into the stomach. The muscles then close rapidly to prevent the food or drink from leaking out of the stomach back into the esophagus and mouth.

In some people, washback of acids will cause irritations or ulcerations of the esophagus. As a result, the esophagus tries to repair itself from inflammation or ulceration by repairing the original cell lining. In 12% of patients, this replacement lining will not be the original type found in the esophagus, but more like that of the stomach.

The formation of a new lining similar to the stomach is known as Barrett's esophagus. Estimated to affect 1.6 to 6.8 percent of people, men develop Barrett’s esophagus twice as often as women, and Caucasian men are affected more frequently than men of other races. Barrett’s esophagus is uncommon in children.

Also, people with Barrett's esophagus are at increased risk for a rare type of cancer called esophageal adenocarcinoma.

What are the symptoms of Barrett's esophagus?

• recurring heartburn
• pain in the chest, upper abdomen and back
• difficulty swallowing food

What causes Barrett's esophagus?

 

Gastroesophageal reflux disease (GERD) is known to most people as heartburn. GERD occurs when acid in your stomach flows up into your esophagus. It is common to develop heartburn at some point in one's life. Usually, modifying diet, avoiding foods high in fat, and minor lifestyle changes correct this condition.

In some patients, heartburn does not go away, and over time the acids in the stomach damage the cells in the esophagus to the extent that they cannot repair themselves ... and this can lead to Barrett's esophagus. Between 5–10 percent of people with GERD end up developing this condition.

What are the risk factors of Barrett's esophagus?

• obesity (especially in men who store large amounts of belly fat)
• smoking
• consuming rich foods high in fat (which forces the stomach to produce lots of acid to break down the food)
• possible genetic predisposition

How is Barrett's esophagus diagnosed?

Barrett's esophagus is diagnosed with an upper GI endoscopy and biopsy. Upper GI endoscopy involves using an endoscope —a small, flexible tube with a light— to see the upper GI tract. The test is performed at a hospital or outpatient center by a gastroenterologist, a doctor who specializes in digestive diseases.

The endoscope is carefully fed down the esophagus and into the stomach and duodenum. A small camera mounted on the endoscope transmits a video image to a monitor allowing close examination of the intestinal lining. A person may receive a liquid anesthetic that is gargled or sprayed on the back of the throat. An intravenous (IV) needle is placed in a vein in the arm if general anesthesia is given. The test may show changes in the esophageal lining.

Barrett's esophagus can be difficult to diagnose because not all tissue in the esophagus is affected. And even though the gastroenterologist will take biopsy samples (using the endoscope) from multiple areas of the esophageal lining, the part of the esophagus with cells showing the condition may still be missed. When viewed through an endoscope, Barrett's tissue doesn't always look different from normal tissue, thus the difference can often only be seen with a microscope.

A pathologist, a doctor who specializes in diagnosing diseases, examines the tissue in a lab with a microscope to determine whether Barrett's esophagus cells are present. The test results may need to be further confirmed by a specialized pathologist who has expertise in diagnosing this condition.

Researchers are working on improved methods for diagnosing Barrett's esophagus.

What is the risk of cancer with Barrett's esophagus?

The risk of esophageal adenocarcinoma —cancer of the esophagus— in people with Barrett's esophagus is about 0.5 percent per year. Typically, before esophageal adenocarcinoma develops, precancerous cells appear in the Barrett's tissue. This condition is called dysplasia and is classified as either low grade or high grade.

Barrett's esophagus may be present for many years before cancer even develops. A periodic upper GI endoscopy with biopsy is often used to monitor people with Barrett's esophagus and watch for signs of cancer development. In most cases, more frequent endoscopies are recommended for people with high-grade dysplasia compared with low-grade or no dysplasia.

H. pylori and Barrett's esophagus

H. pylori (or Helicobacter pylori) infection may decrease the risk of developing Barrett's esophagus. H. pylori is a spiral-shaped bacterium found in the stomach that damages the stomach and the tissue in the duodenum (the first part of the small intestine). The mechanism by which H. pylori provides protection from Barrett's esophagus is unclear. Some researchers believe the bacteria can actually make the stomach contents less damaging to the esophagus when GERD is present.

Other factors that may reduce the risk of developing Barrett's esophagus include frequent use of aspirin (or other nonsteroidal anti-inflammatory drugs) and high intake of fruits, vegetables, and vitamins.

Treatment for Barrett's esophagus

A health care provider will discuss treatment options for Barrett's esophagus based on the person's overall health, whether dysplasia is present, and, if so, the severity of the dysplasia. Treatment options include

• medication
• diet and nutrition
• endoscopic ablative therapies
• endoscopic mucosal resection
• cryoablation
• surgery

Medication

People with Barrett's esophagus who have GERD are typically treated with acid-suppressing medications called proton pump inhibitors. These medications are used to prevent further damage to the esophagus and, in some cases, heal existing damage.

For people with GERD symptoms who do not respond to medications, anti-reflux surgery may be considered. However, medications and/or surgery for GERD and Barrett's esophagus have not been shown to lower a person's risk of dysplasia or esophageal adenocarcinoma.

Diet and Nutrition

People can make dietary changes to lower their risk of Barrett's esophagus. A high intake of fruits, vegetables, and vitamins may help prevent the disease. In addition, for people who are overweight, losing weight may reduce their risk. People should talk with their health care provider about dietary changes that can help prevent Barrett's esophagus.

Endoscopic Ablative Therapies

Endoscopic ablative therapies use different techniques to destroy the dysplastic cells in the esophagus. The body should then begin making normal esophageal cells. These procedures are performed by a radiologist, a doctor who specializes in medical imaging. Local anesthesia and a sedative are used. The procedures most often used are photodynamic therapy and radiofrequency ablation.

Photodynamic Therapy

Photodynamic therapy uses a light-activated chemical called porfimer, an endoscope, and a laser to kill precancerous cells in the esophagus. When porfimer is exposed to laser light, it produces a form of oxygen that kills nearby cells. Porfimer is injected into a vein, and the person returns 24 to 72 hours later to complete the procedure. The laser light passes through the endoscope and activates the porfimer to destroy Barrett's tissue in the esophagus.

Radiofrequency Ablation

Radio frequency ablation uses radio waves to kill precancerous and cancerous cells. An electrode mounted on a balloon or endoscope delivers heat energy to the Barrett's tissue. Complications include chest pain, cuts in the mucosal layer of the esophagus, and strictures (a narrowing of the esophagus). Clinical trials have shown a lower incidence of side effects for radiofrequency ablation compared with photodynamic therapy.

Endoscopic Mucosal Resection (EMR)

Endoscopic mucosal resection involves lifting the Barrett's lining and injecting a solution underneath or applying suction to the lining and then cutting the lining off. The lining is then removed with an endoscope. Just as with endoscopic ablative therapies, this procedure is performed by a radiologist and uses a local anesthesia and sedative. If endoscopic mucosal resection is used to treat cancer, an endoscopic ultrasound is done first to make sure the cancer involves only the top layer of esophageal cells. Ultrasound uses a device called a transducer that bounces safe, painless sound waves off organs to create an image of their structure.

Cryoablation

Cryoablation for the treatment of Barrett's esophagus involves freezing the area where Barrett's has been confirmed. This is a relatively new technique that shows much promise.

Surgery

Surgery for Barrett's esophagus is an alternative; however, endoscopic therapies are preferred by many health care providers due to fewer complications following the procedure.

Esophagectomy is surgical removal of the affected sections of the esophagus. After removal, the esophagus is rebuilt from part of the stomach or large intestine. The procedure is performed by a surgeon at a hospital, and general anesthesia is used. The patient stays in the hospital for 7–14 days after the surgery to recover. Surgery may not be an option for people with Barrett's esophagus who have other medical problems. For these people, the less-invasive endoscopic treatments or continued intensive monitoring would be considered.

Much of the information on this page was derived from the National Digestive Diseases Information Clearinghouse (NDDIC).