Barett's Esophagus

What is Barrett's esophagus?

Barrett's esophagus results from an irritation in the lining of the esophagus (food tube) caused by chronic reflux (flowing backward) of the contents from the stomach and small intestine into the esophagus. The irritation causes the lining of the esophagus to change and become similar to the lining of the intestine and stomach.

What are the symptoms of Barrett's esophagus?

Barrett's esophagus does not cause signs or symptoms, but because there is a strong link between gastroesophageal reflux disease (GERD) and Barrett's esophagus, symptoms of Barrett's esophagus may be similar to those of GERD. The symptoms might include:

• A burning sensation under the chest
• Regurgitation (backing up) of stomach acids
• Difficulty swallowing (Note: This symptom requires immediate medical attention)

What are risk factors associated with Barrett's esophagus?

There are a number of risk factors for the development of Barrett's esophagus, including:

• Symptoms of GERD
• Obesity
• Increasing age
• Caucasian ethnicity
• Male gender
• Family history of Barrett's esophagus

How is Barrett's esophagus diagnosed?

The only way to confirm the diagnosis of Barrett's esophagus is with a test called an upper endoscopy. This involves inserting a small lighted tube (endoscope) through the throat and into the esophagus to look for a change in the lining of the esophagus.

While the appearance of the esophagus may suggest Barrett's esophagus, the diagnosis can only be confirmed with small samples of tissue (biopsies) obtained through the endoscope. A pathologist will examine the tissue to make the diagnosis.

How is Barrett's esophagus treated?

The treatment of Barrett's esophagus is similar to the treatment of GERD. Treatment might begin with lifestyle changes, including:

• Not eating certain foods
• Not eating late in the evening
• Not smoking

Treatment is also likely to include the use of medications that will decrease acid production by the stomach. Patients with Barrett's esophagus typically need prescription medications -- such as omeprazole (Prilosec®), lansoprazole (Prevacid®), pantoprazole (Protonix®), rabeprozole (Aciphex®), esomeprazole (Nexium®), or dexlansoprazole (Kapidex®)-- to reduce acid. Omeprazole is now available as an over the counter preparation as well. These medications are typically given before breakfast once a day or, on occasion, before breakfast and dinner. H2 receptor antagonists are available as prescriptions or as over-the-counter medications. Tagamet®, Zantac®, Axid®, and Pepcid® are generally not as effective in decreasing the acid damage to the esophagus that causes Barrett's esophagus, but they may relieve symptoms for some patients.

All patients with Barrett's esophagus who are in reasonably good health should undergo endoscopic surveillance at appropriate intervals:

• Patients with no dysplasia (unusual changes or growths) on two endoscopies done one year apart should have follow-up endoscopy done at 3-year intervals.
• Patients with low-grade dysplasia should first have their biopsies confirmed by an expert gastrointestinal (GI) pathologist. Endoscopy should be repeated within 6 months and then every year until two in a row are negative before resuming surveillance at 3-year intervals.
• Patients with high-grade dysplasia should have their biopsies reviewed by an expert GI pathologist, and then have an endoscopy with meticulous biopsies and endoscopic resection (removal) of any mucosal abnormalities within 3 months to exclude unsuspected cancer.

What complications are associated with Barrett's esophagus?

Barrett's esophagus is a premalignant (precancerous) condition that may lead to the development of cancer of the esophagus in a small number of patients. The risk of developing cancer is approximately 0.5% each year. This type of cancer is called esophageal adenocarcinoma.

Esophageal cancer develops through a sequence of changes in the cells of the esophagus known as dysplasia. Dysplasia can only be detected by endoscopic biopsies. Patients with Barrett's esophagus should have regular surveillance exams to detect cancer at an early and potentially curable stage.

How is Barrett's esophagus with dysplasia or cancer treated?

Current treatments for Barrett's esophagus with dysplasia or cancer include photodynamic therapy, radiofrequency ablation, cryotherapy, endoscopic mucosal resection, or surgical removal of almost all the esophagus.

• Photodynamic therapy combines a light-sensitizing substance (Photofrin®) with the use of a laser. The Barrett's lining is destroyed, along with the cancerous and precancerous tissue. This is rarely used anymore due to the cost, side effects, and problematic long-term results.
• Radiofrequency ablation involves the use of radiofrequency energy (an energy delivered via electrodes that is similar to microwave energy) to destroy Barrett's lining and replace it with normal esophageal cells. Results are promising for the treatment of low-grade dysplasia and high-grade dysplasia. The use of radiofrequency ablation for nondysplastic Barrett's esophagus is controversial at present.
• Cryotherapy involves freezing the lining of the esophagus and then replacing with normal esophageal cells. This technique is still experimental and is currently under study.
• Endoscopic mucosal resection involves removing abnormal areas of Barrett's lining by the use of an endoscopically placed snare (similar to what is used for colon polyps). Unlike other endoscopic techniques, endoscopic mucosal resection allows for tissue confirmation by a pathologist. Any mucosal abnormalities should be removed by endoscopic mucosal resection prior to using other endoscopic or surgical techniques.
• Surgical treatment of Barrett's esophagus with cancer is used only when the patient is strong enough to handle surgery and has high-grade dysplasia or cancer. If surgery is chosen as a treatment, virtually the entire esophagus is removed and the stomach is pulled up into the neck.