Barrett’s Esophagus

What is Barrett’s esophagus?

Barrett’s esophagus is a condition where the lining of the esophagus changes due to GERD and this change increases the risk of esophageal adenocarcinoma. It is believed to be a reparative response to reflux induced damage to the normal squamous lining of the esophagus, with subsequent replacement with Barrett’s esophagus. In other words, in the setting of chronic acid exposure, the cellular structure of the lower esophageal lining changes to look more like the cells lining the intestine. However, Barrett’s esophagus itself produces no specific symptoms different from those of standard GERD.

Why be concerned about Barrett’s esophagus?

There is an increasing number of people per year diagnosed with esophageal adenocarcinoma in the U.S. Barrett’s esophagus is the primary risk factor for this type of cancer perhaps related to increasing rates of obesity and acid reflux. Esophageal cancer, like most cancers, when detected at a late stage has a very poor prognosis. Detection at earlier stages has a better prognosis and screening and surveillance for Barrett’s esophagus may save lives, though that has not been definitively demonstrated.

How is Barrett’s esophagus diagnosed?

The only way to detect Barrett’s esophagus is to undergo upper endoscopy where Barrett’s esophagus can be confirmed by biopsies. The intent of screening for Barrett’s esophagus is to diagnose this condition, treat it as needed and follow it over time to detect dysplasia or early cancer. If biopsies detect dysplasia (a worsening precancerous change in tissue), then your doctor may recommend either closer endoscopic surveillance (doing endoscopies with biopsies at shorter time intervals) and/or endoscopic therapy to remove the abnormal tissue.

Who should get screening and surveillance for Barrett’s esophagus?

It is recommended that individuals with longstanding reflux (longer than 5 years) should undergo screening for this condition. Barrett’s esophagus and esophageal cancer is also more common in older patients (> age 50) and in Caucasian males. If a patient is found to have Barrett’s esophagus without dysplasia, they should have a surveillance endoscopy every three to five years to monitor for dysplasia and early cancer. Surveillance endoscopy intervals for Barrett’s esophagus with dysplasia are even shorter. Early detection of esophageal cancer is associated with improved survival rates. See Table 2 regarding surveillance in ASGE’s guideline The role of endoscopy in Barrett’s esophagus and other premalignant conditions of the esophagus.

How is Barrett’s esophagus treated?

Patients with Barrett’s esophagus have GERD and should be treated for GERD, as noted above, usually with proton pump inhibitors. Endoscopic therapy can eradicate Barrett’s esophagus with or without dysplasia. Endoscopic therapy can be divided into therapies that ablate mucosa and techniques that resect mucosa. A key element of the endoscopic therapy of Barrett’s esophagus is that re-epithelialization with normal squamous mucosa (that is, return of the esophagus lining to normal tissue) can only be achieved in an acid-suppressed environment; thus, the use of anti-secretory agents or anti-reflux surgery is a necessary adjunct to these techniques.

most common method of mucosal ablation destroys and kills abnormal cells by heating them using thermal energy called radiofrequency ablation (RFA). RFA can be delivered using cylinder shaped balloons or touch pads passed into the esophagus under endoscopic guidance. Multiple studies have demonstrated that this is a very safe, effective method to treat Barrett’s esophagus. Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are endoscopic techniques designed to remove targeted superficial tissue of the GI tract (EMR) or large en bloc strips of mucosa (ESD). Both techniques actually remove abnormal tissue (rather than ablate it) in the esophagus and allow for full pathological evaluation. Your gastroenterologist can help determine if and which type of endoscopic treatment option is best for you.