Barrett's esophagus is a complication of chronic esophageal exposure to the refluxed
gastric acid (see GERD), characterized by changes in the esophageal lining that replace
the native lining with an intestinal type of lining (intestinal metaplasia).
Although the new intestinal lining (mucosa) may be more resistant to gastroesophageal
reflux (GERD) than the native mucosa, the metaplastic cells are predisposed to cancer.
Heartburn is a very common condition affecting approximately 20 million people every
day and about 40 million people at least once a week.
However, only a small percentage of people with chronic heartburn (GERD) develop
Barrett's esophagus (BE). BE is found in 6-12% of patients undergoing endoscopy for
symptoms of GERD, and in 1% of unselected patient populations undergoing endoscopy.
However, this prevalence may be underestimated due to the fact that some patients with BE
may have mild or no reflux symptoms.
The majority of patients with BE have the most severe reflux of any patient group. They
have more abnormal esophageal contractions and more esophageal acid exposure than patients
with reflux esophagitis uncomplicated by BE.
The average age at the time of diagnosis is 55 years and the white men have the highest
incidence.
The patients with BE are at a much higher risk of developing esophageal adenocarcinoma
than the general population. Although increased, the absolute risk of esophageal cancer
for any patient with Barrett's esophagus is less than 1% a year.
The symptoms of Barrett's esophagus are similar to those of GERD, and include:
- burning pain behind the breastbone and in the throat
- chest pain similar to heart attack
- hoarseness and/or dry cough in the morning
- dysphagia (difficulty in swallowing)
- loss of appetite
- weight loss
- anemia due to chronic bleeding
Some patients with Barrett's esophagus may not have any symptoms related to
gastroesophageal reflux.
The diagnosis of Barrett's esophagus cannot be made on the basis of symptoms, physical
exam or blood tests. The only diagnostic test that can be employed is upper endoscopy and
biopsy. During endoscopy a thin tube equipped with a video camera is pushed down the
esophagus and stomach. The images of the esophageal and gastric lining captured by the
video camera are projected on a monitor and examined by the doctor. Barrett's esophagus is
characterized by a change in the color of the esophageal lining (mucosa) from white-gray
to salmon-pink. To confirm the presence of Barrett's esophagus, small tissue samples
(biopsies) can be removed using a small forceps attached to the endoscope. The biopsies
are sent to the pathology laboratory for processing (for detailed information on tissue
processing click
here) and microscopic examination by specialized physicians (pathologists).
Barrett's esophagus has a long, chronic clinical course that may be complicated by a
high risk premalignant lesion called dysplasia in 8-14% of the patients, and by esophageal
adenocarcinoma in less than 1% of patients. Dysplasia is a premalignant condition in which
cancer cells appear in the Barrett's esophagus, but do not have the ability to spread at
distant sites. There are two different types of dysplasia categorized on the basis of the
extent and severity of cell features: low-grade and high-grade dysplasia. Each of these
categories of dysplasia has a different risk of developing Barrett's adenocarcinoma (it is
much higher in high-grade dysplasia).
Dysplasia can only be diagnosed by microscopic examination of the biopsies removed at
the time of endoscopy.
Periodic endoscopic examination of the esophagus (called surveillance) to detect the
early signs of cancer, is recommended in the patients with Barrett's esophagus. The time
interval between endoscopies performed during Barrett's esophagus surveillance is variable
depending on the extent and severity of the lesions: 2-3 years in patients with
uncomplicated Barrett's esophagus, every 6 months for 1 year, and then yearly in patients
with low-grade dysplasia, and expert confirmation followed by resection of esophagus or
continued surveillance every 3 months in patients with high-grade dysplasia.
The treatment of uncomplicated Barrett's esophagus is similar to the treatment for
gastroesophageal reflux disease, consisting of lifestyle changes and potent anti-acid
medication (proton pump inhibitors, such as Nexium). This approach to Barrett's esophagus
may result in improvement of the extent of Barrett's tissue, but may not cure the disease
or reduce the risk of cancer.
For patients with complicated Barrett's esophagus (high-grade dysplasia or cancer),
surgical removal of the esophagus (esophagectomy) offers the only chance for cure. During
the surgery the lower portion of the esophagus is removed and the stomach is pulled up in
the chest and sutured to the upper portion of the esophagus. After this type of surgery,
the recovery may take up to six weeks and an estimated weight loss of 10-20 lbs is
expected.
Additional information about esophageal disorders:
American Gastroenterological Association
National Institutes of Health
Mayo Clinic
Cleveland Clinic Foundation
