Barrett’s Esophagus

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Heartburn is a burning sensation felt behind the breastbone and sometimes in the neck and throat. It is caused by stomach acid refluxing or flowing up into the esophagus – the muscular tube that connects the throat to the stomach. At the lower end of the esophagus where it enters the stomach, there is a strong muscular ring called the Lower Esophageal Sphincter (LES). The LES should remain tightly closed, except to allow food and liquid to pass into the stomach. Heartburn occurs when the LES opens at the wrong time. Almost everyone has this occasionally, and it is nothing to be concerned about. However, heartburn that is severe, frequent or that occurs repeatedly over a long period of time can be harmful. This is known as Gastroesophageal Reflux Disease (GERD). Left untreated, GERD causes constant acid irritation to the lining of the esophagus and complications can occur. About 1 in 10 patients with GERD are also found to have a condition called Barrett’s esophagus, which can be serious and may lead to cancer of the esophagus.

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 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 stomach or intestinal-type cells above this border, into the esophagus. The Barrett’s tissue may spread evenly up into the esophagus, or it may present as islands or finger-like projections. Usually it is found in the lower portion of the esophagus; however, it may extend throughout the esophagus.

Since the cells lining the stomach are accustomed to contact with acids, their growth in the esophagus may actually be a defense mechanism. It is designed to protect the normal tissue in the esophagus against further damage by GERD. This may explain why the symptoms of GERD seem to lessen in some patients with Barrett’s esophagus. Unfortunately, these tissue changes 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 cancer appears to be decreasing in the population, while the rate of adenocarcinoma is increasing sharply, especially in white males.

After many years, the Barrett’s cells in some patients may develop abnormal changes known as dysplasia. These changes may be in the size or appearance of cells, or in the way cells grow. Over a period of time, the dysplasia may progress from low grade, to high grade, and finally to cancer. Fortunately, this happens only in about 5-10 percent of patients with Barrett’s esophagus.

For unknown reasons, Barrett’s esophagus is found more often in males than in females. Current evidence is strong that in most instances, Barrett’s esophagus develops as a result of chronic or longstanding GERD.

In most cases, patients with Barrett’s have symptoms similar to those produced by chronic GERD. Some Barrett’s patients may also suffer from other complications of GERD, such as peptic ulcers, bleeding and stricture – narrowing of the esophagus that comes from scarring. GERD patients with excess acid production or frequent reflux of bile are more likely to develop Barrett’s esophagus. This is why it is important for patients with frequent or severe heartburn to see their physicians regularly.

Diagnosis of Barrett’s esophagus requires an endoscopic examination where the physician examines the lining of the esophagus and stomach with a thin, lighted flexible tube called an endoscope. This is done with the patient under sedation. Biopsies, or painless sampling of tissue, are performed to examine under a microscope for dysplasia, or precancerous tissue. If there is dysplasia, then follow-up exams must be performed.

Other than investigative treatments using photodynamic therapy, there is no recognized treatment to reverse Barrett’s esophagus. However, it appears that treating the underlying GERD may slow the progress of the disease and prevent complications. The following are some things the patient can do to help reduce acid reflux and strengthen the LES without medication:

Avoid eating anything within three hours before bedtime or lying down.
Avoid smoking and tobacco products. Nicotine in the blood weakens the LES.
Avoid fatty foods, chocolate, cocoa, 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 weaken the LES.
Elevate the head of the bed or mattress 2 to 4 inches. This helps to keep acid in the stomach by gravity. Pillows by themselves are not very helpful.
Lose weight if overweight. This may relieve upward pressure on the stomach and LES.
The physician may prescribe medications for acid reduction such as Zantac ®, Pepcid ®, Axid ®, and Tagamet ®. Newer medications, such as Prilosec ®, Prevacid ®, Adiphex ®, Protonix ® and Nexium ® can almost eliminate stomach acid entirely. These drugs are almost always needed to treat severe GERD. Reglan ® is a drug that can strengthen the LES.

Certain patients with GERD may need surgery to strengthen the LES. This type of surgery is called fundoplication. It is often done by laparoscopy. Laparoscopy is minimally invasive surgery, performed with a tiny incision at the navel and a few needle points in the upper abdomen. The patient usually returns home in 1-2 days. Nonsurgical or endoscopic ways to correct GERD are currently being developed and tested.

A diagnosis of Barrett’s esophagus requires regular monitoring by a physician. While it is thought that controlling GERD reduces the risk of developing cancer, this has not yet been definitely proven. Therefore, the physician must perform regular endoscopy exams and biopsies to look for dysplasia. Just how often these exams are repeated depends on how far the disease has advanced. If advanced cancer is found, surgery to remove the lower esophagus (esophagectomy) is usually necessary.

Barrett’s esophagus is a condition that may develop as a result of chronic GERD. Barrett’s tissue growing in the esophagus is the body’s defense against continued stomach acid irritation. Yet, that tissue does not belong in the esophagus, and for some patients, it increases the risk of developing adenocarcinoma (cancer) of the esophagus. The likelihood of developing cancer and complications may be reduced with a combination of diet, lifestyle changes, medication and/or surgery. A regular program of endoscopic examination and biopsy is essential to monitor the Barrett’s tissue. New endoscopic treatments including mucosal resection, radiofrequency ablation (BARRx;HALO) and photodynamic therapy are available in our practice to treat Barrett’s esophagus, dysplasia and some cases of early cancer. By working closely with a physician, patients with Barrett’s esophagus can expect good control of both GERD and Barrett’s and an excellent long-term outcome.