Barrett's Esophagus

 

 

Barrett's esophagus is a condition in which the tissue lining the esophagus, the muscular tube that connects the mouth to the stomach, is replaced by tissue that is similar to the lining of the intestine. This process is called intestinal metaplasia. The disease is also referred to as simply Barrett''s or by the acronym BE.

 

While Barrett's esophagus itself has no symptoms, it is usually found in persons who have gastroesophageal reflux disease (GERD), which does (see below). Persons with with BE are thirty times more likely to develop adenocarcinoma of the esophagus, a type of esophageal cancer, than the general population, However in comparison to the total number of persons with Barrett's, the number who develop esophageal cancer is small.

 

For patients having Barrett's esophagus with severe or high-grade dysplasia, the definitive treatment is a prophylactic esophagectomy. This procedure is performed at UCSF by a highly experienced surgical team, a thoracic surgeon and general surgeon who perform the procedure in high volume, using minimally invasive techniques when possible. During the surgery,  most or all of the esophagus is removed, a portion of the stomach is pulled up into the chest, and the remaining esophagus is attached to the stomach. 

 

Barrett's esophagus affects about one percent of adults in the United States. The average age at diagnosis is 50, but determining when the problem started is usually difficult. Men develop Barrett's esophagus twice as often as women, and Caucasian men are affected more frequently than men of other races. Barrett's esophagus is uncommon in children. 

 

About the Esophagus

The esophagus carries food and liquids from the mouth to the stomach. The stomach slowly pumps the food and liquids into the intestine, which then absorbs needed nutrients. This process is automatic and people are usually not aware of it. People sometimes feel their esophagus when they swallow something too large, try to eat too quickly, or drink very hot or cold liquids.

 

The muscular layers of the esophagus are normally pinched together at both the upper and lower ends by muscles called sphincters. When a person swallows, the sphincters relax to allow food or drink to pass from the mouth into the stomach. The muscles then close rapidly to prevent the food or drink from leaking out of the stomach back into the esophagus and mouth.

 

GERD and Barrett's Esophagus

GERD (Gastroesophageal Reflux Disease) is a more serious form of gastroesophageal reflux (GER). GER occurs when the lower esophageal sphincter opens spontaneously for varying periods of time or does not close properly and stomach contents rise into the esophagus. GER is also called acid reflux or acid regurgitation because digestive juices called acids rise with the food or fluid.

 

When GER occurs, food or fluid can be tasted in the back of the mouth. When refluxed stomach acid touches the lining of the esophagus it may cause a burning sensation in the chest or throat called heartburn or acid indigestion. Occasional GER is common and does not necessarily mean one has GERD.

 

Persistent reflux that occurs more than twice a week is considered GERD and can eventually lead to more serious health problems. Overall, 10 to 20 percent2 of Americans experience GERD symptoms every day, making it one of the most common medical conditions. People of all ages can have GERD.

 

People who have GERD symptoms should consult with a physician. If GERD is left untreated over a long period of time, it can lead to complications such as a bleeding ulcer. Scars from tissue damage can lead to strictures-narrowed areas of the esophagus-that make swallowing difficult. GERD may also cause hoarseness, chronic cough, and conditions such as asthma.

GERD is a risk factor for Barrett's Esophagus, 3-5 times more common in those who also have GERD.

 

Since Barrett's Esophagus is more commonly seen in people with GERD, most physicians recommend treating GERD symptoms with acid-reducing drugs. Improvement in GERD symptoms may lower the risk of developing Barrett's Esophagus. A surgical procedure may be recommended if medications are not effective in treating GERD.

 

Diagnosis

 

Because Barrett's esophagus does not cause any symptoms, many physicians recommend that adults older than 40 who have had GERD for a number of years undergo an endoscopy and biopsies to check for the condition.

Barrett's esophagus can only be diagnosed using an upper gastrointestinal (GI) endoscopy to obtain biopsies of the esophagus. In an upper GI endoscopy, after the patient is sedated, the doctor inserts a flexible tube called an endoscope, which has a light and a miniature camera, into the esophagus.

 

If the tissue appears suspicious, the doctor removes several small pieces using a pincher-like device that is passed through the endoscope. A pathologist examines the tissue with a microscope to determine the diagnosis.

 

Risk of Esophageal Cancer with Barrett's Esophagus

 

Smoking, heavy alcohol use, and Barrett esophagus can increase the risk of developing esophageal cancer. Barrett's esophagus may be present for several years before cancer develops. Approximately 1% of people with Barrett's esophagus develop a type of esophageal cancer called esophageal adenocarcinoma each year.

 

Esophageal adenocarcinoma is frequently not detected until its later stages when treatments are not always effective.

 

Surveillance for Dysplasia and Cancer

 

Periodic endoscopic examinations with biopsies to look for early warning signs of cancer are generally recommended for people who have Barrett's esophagus. This approach is called surveillance.

Typically, before esophageal cancer develops, precancerous cells appear in the Barrett's tissue. This condition is called dysplasia and can be seen only through biopsies. Multiple biopsies must be taken because dysplasia can be missed in a single biopsy. Detecting and treating dysplasia may prevent cancer from developing.

Treatment

 

Endoscopic or surgical treatments are used to treat Barrett's esophagus that is accompanied by high grade (severe dysplasia)  or esophageal cancer.

 

Endoscopic Treatments

 

Several endoscopic therapies are available to treat severe Barrett's with severe dysplasia or esophageal cancer in which the Barrett's lining is destroyed or the portion of the lining that has dysplasia or cancer is removed. The goal of the treatment is to encourage normal esophageal tissue to replace the destroyed Barrett's lining. Endoscopic therapies are performed at specialty centers by physicians with expertise in these procedures.

 

• Photodynamic Therapy (PDT). PDT uses a light-sensitizing agent called Photofrin and a laser to kill precancerous and cancerous cells. Photofrin is injected into a vein and the patient returns 48 hours later. The laser light is then passed through the endoscope and activates the Photofrin to destroy Barrett's tissue in the esophagus. Complications of PDT include chest pain, nausea, sun sensitivity for several weeks, and esophageal strictures.

• Endoscopic Mucosal Resection (EMR). EMR involves lifting the Barrett's lining and injecting a solution under it or applying suction to it and then cutting it off. The lining is then removed through the endoscope. If EMR is used to treat cancer, an endoscopic ultrasound is done first to make sure the cancer involves only the top layer of esophageal cells. The ultrasound uses sound waves that bounce off the walls of the esophagus to create a picture on a monitor. Complications of EMR can include bleeding or tearing of the esophagus. EMR is sometimes used in combination with PDT.   

 

Surgery

 

Surgical removal of most of the esophagus is recommended if a person with Barrett's esophagus is found to have severe dysplasia or cancer and can tolerate a surgical procedure. Many people with Barrett's esophagus are older and have other medical problems that make surgery unwise; in these people, the less-invasive endoscopic treatments would be considered.

 

Surgery soon after diagnosis of severe dysplasia or cancer may provide a person with the best chance for a cure. The type of surgery varies, but it usually involves removing most of the esophagus, pulling a portion of the stomach up into the chest, and attaching it to what remains of the esophagus.

 

Summary

• In Barrett's esophagus, the tissue lining the esophagus is replaced by tissue that is similar to the lining of the intestine.

• Barrett's esophagus is associated with gastroesophageal reflux disease (GERD).

• Improvement in GERD symptoms with acid-reducing drugs may decrease the risk of developing Barrett's esophagus.

• Barrett's esophagus is diagnosed through an upper gastrointestinal endoscopy and biopsies.

• People who have Barrett's esophagus should have periodic surveillance endoscopies and biopsies.

• Endoscopic treatments are used to destroy Barrett's tissue, which will hopefully be replaced with normal esophageal tissue.

• Removal of most of the esophagus is recommended if a person with Barrett's esophagus is found to have severe dysplasia or cancer and can tolerate a surgical procedure.