The esophagus is the tube that connects the mouth with the stomach. Barrett’s esophagus occurs when the normal cells that line the lower part of the esophagus (called squamous cells) are replaced by a different cell type (called intestinal cells). The importance of recognition of Barrett’s is that it can lead to esophageal cancer in some people.
This transformation probably occurs as a result of chronic reflux of acid into the esophagus from the stomach. As a reaction to acid, not normally present in significant amounts in the esophagus, the esophageal cells change to intestinal cells (which are more used to acid exposure). Sometimes this change goes awry and turn into cancer cells.
RISK FACTORS FOR BARRETT’S
Chronic acid reflux is the primary risk factor. This can occur in people with heartburn but also may occur with no warning symptoms.
Barrett’s esophagus is most commonly diagnosed in middle-aged and older adults; the average age at diagnosis is 55 years.
Men are somewhat more commonly diagnosed with Barrett’s esophagus than women.
Smokers are more commonly diagnosed with Barrett’s esophagus than nonsmokers.
Obesity/over weight is a significant risk factor for the development of Barrett’s.
Barrett’s esophagus itself produces no symptoms. As the underlying process is related to acid reflux, heartburn and regurgitation of stomach contents are commonly noticed. Unfortunately, acid reflux can occur and cause no symptoms and Barrett’s (and cancer) can develop with no warning signs.
Barrett’s is diagnosed by endoscopy and biopsy. Endoscopy is performed in a sedated patient by examining the esophagus and upper GI tract with a flexible scope. If there is a visible change that may indicate Barrett’s, biopsies are performed by taking small pinches of the suspected areas during the endoscopy. This does not hurt. Examination under the microscope looks for changes of Barrett’s and possible precancerous or even cancerous cells.
The mainstay of treating Barrett’s involves removing the offending agent – acid reflux. This usually requires taking medications that partially block the ability of the stomach to produce acid. Most commonly, a proton pump inhibitor (PPI) is used. Examples of PPI’s are omeprazole, pantoprazole, Prevacid, Nexium, Prilosec, Aciphex, Zegerid, and Dexilant.
Weight loss if overweight, avoiding eating and drinking within 3 hours of going to bed, and moderation of caffeine and alcohol may help. Quitting smoking is important.
Monitoring for precancerous (or cancerous) changes is recommended for most patients with Barrett’s esophagus by preforming endoscopy and obtaining biopsies. The interval between endoscopies can vary and can be from annually to every 5 years. A persons underlying health or advanced age may affect a recommendation when to have a follow up endoscopy, if at all.
Barrett’s can predispose to esophageal cancer. There is usually a precancerous stage, called dysplasia that is diagnosed by the appearance of the cells obtained during endoscopy. Dysplasia can progress to esophageal cancer. Progression to cancer is uncommon; studies that follow patients with Barrett’s esophagus reveal that only 0.5 percent of patients develop esophageal cancer per year.
TREATMENT OF DYSPLASIA AND ESOPHAGEAL CANCER IN BARRETT’S
If precancerous changes (dysplasia) are discovered, we usually ask for confirmation by a second pathologist opinion. It is sometimes difficult to correctly identify precancerous changes, especially when there is acid reflux related inflammation. The precancerous changes are graded as “low grade dysplasia” or “high grade dysplasia,” depending upon their severity. Patients with low grade dysplasia are usually told to increase their dose of acid suppressing medication and undergo a repeat endoscopy in a few months. High grade dysplasia has a much higher risk of becoming cancer and requires more aggressive treatment.
Radiofrequency Ablation – This is an endoscopic technique in which a special catheter with electrodes is either attached to the end of the endoscope or a balloon with these electrodes is inserted into the esophagus. The electrodes provide thermal (heat) energy which destroy the Barrett’s tissue. This often results in normal esophageal tissue growing back. This technique often requires two to three procedures to completely remove the Barrett’s tissue.
Endoscopic Mucosal Resection – This is an endoscopic procedure to determine the extent of dysplasia (how deep the cells invade the wall of the esophagus) while at the same time removing the (pre-)cancerous cells. Endoscopic mucosal resection is done with an endoscope and tool similar to those used to remove polyps in the colon.
Surgery – A surgeon will remove a portion of the esophagus containing the abnormal areas. This type of surgery usually results in long term regurgitation but can more reliably remove all the precancerous and cancerous cells.
Disorders of Esophageal Contraction (Motility Disorders)
Esophageal motility disorders cause abnormalities in the contraction mechanism of the esophagus usually manifesting as non-cardiac chest pain or the sensation that food and/or liquids seem to get hung up in the chest after swallowing. The primary motility disorders are achalasia, diffuse esophageal spasm, nutcracker esophagus, and ineffective peristalsis. Esophageal function is usually assessed with motility testing, also called manometry. We now offer High Resolution Manometry that more accurately evaluates the motor function of the esophagus. Patients with esophageal motility disorders are then treated, for example in achalasia, they may undergo pneumatic endoscopic balloon dilation, BoTox injection, or be referred to a surgeon, as appropriate for each individual circumstance based on detailed consultation.