What is Barrett's Esophagus?
The cells lining the esophagus differ from those lining the stomach or intestines, mainly because they have different functions. They also have a distinctly different appearance, so it is usually easy for a physician to tell them apart when examining the esophagus and stomach. Normally, there is an area at the end of the esophagus that marks the border between the cells of the esophagus and those of the stomach. Barrett's esophagus is the abnormal growth of intestinal-type cells in the esophagus above this border.
The precise reason why Barrett’s Esophagus occurs is not clear. Since the cells lining the stomach and small intestine have protective mechanisms against acid, their growth into the esophagus may be a defense mechanism and could be our body’s attempt to protect the esophagus against further damage by GERD. This may also explain why the symptoms of GERD seem to lessen in some patients with Barrett's esophagus.
In some patients, Barrett’s Esophagus may be a forerunner of cancer of the lower esophagus, known as adenocarcinoma. Cancer of the upper esophagus (squamous cell cancer) is usually related to alcohol and smoking. Squamous cell esophageal cancers are be decreasing in the US population, while the rate of adenocarcinoma is increasing, especially in white males.
In time, the Barrett's cells may develop microscopic changes known as dysplasia. This typically happens slowly over a period of perhaps two to five years. Dysplasia can be progressive from low grade dysplasia, to high grade dysplasia and then finally to cancer (though many patients with low grade dysplasia will progress further). Fortunately, this progression happens only in about 1-5% of patients with Barrett's esophagus.
Heartburn is a burning sensation felt behind the breastbone and sometimes in the neck and throat. It is caused by stomach acid refluxing or splashing up into the esophagus -- the muscular tube that connects the throat to the stomach. Almost everyone has this occasionally, and it is nothing to be concerned about. However, heartburn that is severe or that occurs frequently over a long period of time can be harmful. This is known as Gastroesophageal Reflux Disease (GERD). If GERD is untreated, there is constant acid irritation to the lining of the esophagus, and complications can occur. About 1 in 10 patients with GERD are found to have a condition called Barrett's esophagus. It can be serious and may lead to cancer of the esophagus. Evidence suggests that in most instances, Barrett’s Esophagus develops as a result of longstanding GERD.
For unknown reasons, Barrett's esophagus is found three times more often in males than in females. Progression to cancer is also more common in males than females. Barrett’s is also more common over in people who are overweight, Caucasian, have a hiatal hernia, smokers, and who are over age 50 (but can be present at younger ages, particularly with long standing severe GERD). In rare instances, Barrett's esophagus appears to be congenital (present at birth).
Patients with Barrett's usually have symptoms similar to those produced by chronic GERD, such as heartburn and reflux of stomach acid into the mouth. Some Barrett's patients may also suffer from other complications of GERD, such as esophageal peptic ulcers and stricture -- narrowing of the esophagus that comes from scarring. Barrett’s esophagus by itself causes no specific symptoms which is why it is important for patients with long standing GERD or swallowing problems to see their physicians regularly.
Diagnosis of Barrett's esophagus requires an examination called upper endoscopy or EGD (esophagogastroduodenoscopy). A barium x-ray is not accurate for detecting Barrett's esophagus. An EGD is done with the patient under sedation. The physician examines the lining of the esophagus and stomach with a thin, lighted, flexible endoscope. Biopsies are performed, taking pieces of tissue to be examined under a microscope for abnormal cells and to evaluate for dysplasia.
Diet and Lifestyle Changes for GERD
Currently, there are no medications to reverse Barrett's esophagus. However, it appears that treating the underlying GERD may slow the progress of the disease and prevent complications. Following are some things the patient can do to help reduce acid reflux and strengthen the LES.
- Avoid eating anything within three hours before bedtime.
- Avoid smoking and tobacco products. Nicotine in the blood weakens the LES.
- Reduce consumption of fatty foods, milk, chocolate, mints, caffeine, carbonated drinks, citrus fruits and juices, tomato products, pepper seasoning, and alcohol (especially red wine).
- Eat smaller meals. Avoid tight clothing or bending over after eating.
- Review all medications with the physician. Certain drugs can actually weaken the LES.
- Elevate the head of the bed or mattress 6 to 8 inches. This helps to keep acid in the stomach. Pillows by themselves are not very helpful. Wedging pillows under the head tends to bend the body at the waist which can push more fluid back up into the esophagus.
- Lose weight if overweight. This may relieve upward pressure on the stomach and LES.
Medications for GERD
A certain category of drugs called proton pump inhibitors are the main tool used to reliably reduce stomach acid. These include Prilosec (omeprazole), Prevacid (lansoprazole), AcipHex (rabeprazole), Protonix (pantoprazole) and Nexium (esomeprazole) and others taken once or twice a day. All of these are equally effective despite their marketing. Other acid reducing drugs such as Zantac, Pepcid, Axid, and Tagamet are also available but generally are shorter acting and not as effective alone for moderate and severe GERD.
Surgery for GERD
Certain patients with GERD may need surgery to strengthen the LES. This type of surgery is called fundoplication. It is now usually done by laparoscopy. Laparoscopy is minimally invasive surgery, performed with a tiny incision at the naval and a few needle points in the upper abdomen.
Monitoring of Barrett’s Esophagus
A diagnosis of Barrett's esophagus requires regular monitoring by a physician. While it is thought that controlling GERD reduces the risk of progression and developing cancer, this has not yet been definitely proven. Therefore, the physician must perform regular endoscopy exams and biopsies to look for dysplasia. How often these exams are repeated depends on the biopsy results and how far the disease has progressed (many patients never progress and need infrequent exams). Unfortunately, it is not possible at this time to tell the difference between a patient who will progress to dysplasia or cancer and one who will not.
Treating Barrett’s Esophagus
Most patients with Barrett’s esophagus have no dysplasia, will never progress and therefore need no additional treatment and only periodic monitoring exams.
In patients with dysplasia, treatment can be offered to remove the Barrett’s esophagus. In general, this type of treatment is offered to patients with high grade dysplasia but in certain circumstances may benefit patients with low grade dysplasia. Indefinite for dysplasia means the pathologist is not certain (usually due to GERD injury to the Barrett’s cells) so these patients are typically asked to step up efforts to control GERD and a repeat endoscopy is performed in 3-6 months.
Endoscopic treatments for Barrett’s Esophagus most commonly include BARRx Radiofrequency Ablation (or RFA) or Endoscopic Mucosal Resection (EMR). Some centers also have expertise in Endoscopic Submucosal Dissection (ESD), Cryoablation and Photodynamic Therapy (PDT). Which treatment is chosen depend on both the Barrett’s itself and physician expertise. These treatments destroy or remove the Barrett’s tissue using different methods during an endoscopy. Typically multiple treatments are necessary to completely treat all Barrett’s and close monitoring is necessary for recurrence after treatment. Patients frequently experience esophageal pain (like severe heartburn) after these treatments for several days and up to 5% may develop a scar tissue narrowing due to treatment which causes swallowing difficulty and needs to be dilated.
If cancer is found, surgery to remove the lower esophagus is usually necessary. Historically surgery was recommended when high grade dysplasia was present to prevent progression to cancer. With modern endoscopic treatments this is usually only necessary in a small number of patients who don’t respond to treatment.
There are various newer techniques to screen for Barrett’s and treatments being studied.