What is Barrett's Esophagus?
Barrett's esophagus is a condition which may occur in
as many as 10% of patients with severe gastroesophageal reflux. As a result
of chronic long-standing acid reflux, the normal lining of the lower esophagus
is severely damaged or destroyed. The lining of the stomach then grows
into the esophagus to replace the normal lining. Unfortunately, this lining
is abnormal. It undergoes a change called intestinal metaplasia, which
can be positively identified on biopsy. Further changes such as dysplasia
may occur which lead to the development of esophageal cancer in up to 5-10%
of patients with this condition. If Barrett's esophagus is identified,
the patient should be followed regularly with periodic gastroscopy and
biopsies. The goal of screening is to identify cancer at an early stage
to improve the chances of a surgical cure.
Endoscopic Screening and Dysplasia
Current guidelines suggest that patients with Barrett's esophagus should
undergo gastroscopy every 2-3 years. When the examination is performed, the Barrett's mucosa
is carefully examined and any suspicious areas are biopsied. Random biopsies
are also taken. All the biopsies are carefully examined for signs of dysplasia
or cancer. Dysplasia is a precancerous change which usually occurs before
cancer ever develops. It can be thought of as an early warning signal,
but does not always progress to cancer.
If cancer is found, the patient will undergo preoperative
evaluation and will be referred for surgery. This is a major operation
to remove the cancer and all the Barrett's mucosa. As a general rule, early
cancers detected in patients screened regularly are very likely to be cured.
This is a significant improvement over the usual outcome for patients with
esophageal cancer. Overall, 95% of these patients will die within 5 years.
Esophageal cancer is a very serious and potentially lethal disease. Our
sincere hope is that with careful screening and follow-up, we will be able
to decrease the risk of death from esophageal cancer in this group of patients.
What if Dysplasia is Found?
If high grade dysplasia is found, biopsies will be referred to
an expert pathologist for review. If high grade dysplasia is confirmed there is a high risk of progression to cancer,
or a possibility that a cancer is already present. These patients
need to be followed very closely and most should undergo further evaluation with
endoscopic ultrasound, surgery or advanced endoscopic therapy, even if definite
cancer is not found at endoscopy. Your physician will discuss the options that
are appropriate for your case.
If low grade dysplasia is found and confirmed on expert review
of the biopsies, the patient should undergo repeat endoscopy
in one year. A small percentage of patients with low grade dysplasia will
progress to high grade dysplasia. Chronic reflux results in inflammation and damage to cells
lining the esophagus. The rapid repair and regeneration which occurs in
response to inflammation can sometimes be mistaken for dysplasia. If low grade dysplasia
is found, the patient is placed on medical treatment with a proton pump
inhibitor to completely turn off acid production by the stomach.
Repeat gastroscopy and biopsy is performed in a year. If low grade dysplasia
persists, annual screening should continue.
In some patients, biopsies are interpreted as being indefinite for dysplasia.
The significance of this finding is unclear, but repeat endoscopy is recommended
in one year.
Medical Therapy
All patients with Barrett's esophagus should
be on medication to reduce the amount of acid secreted by the stomach.
It appears that chronic therapy with proton pump inhibitors reduces the risk of
progression to high grade dysplasia and cancer.
Treatment also aids in the relief of symptoms and may also reduce the risk of
forming a stricture or ring of scar tissue. Strictures are the most common
cause of swallowing problems in patients with Barrett's. If you begin to
experience choking or difficulty swallowing, seek medical attention immediately.
This could also be a symptom of esophageal cancer.
Some patients with Barrett's esophagus have very little
heartburn, even though they are experiencing severe reflux and have significant
inflammation. This is in contrast to the person with reflux and minimal
or no inflammation who complains of severe heartburn. The difference is
the level of acid sensitivity. Persons with severe reflux and an esophagus
which is not acid sensitive are more likely to develop and an esophageal
stricture or even Barrett's esophagus. This is because they are less likely
to seek treatment for reflux symptoms. The goal of medical therapy is prevention
of inflammation, scar tissue and cancer of the esophagus.
Even if you have no symptoms, you should follow our recommendations for
patients with heartburn.
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