About Barrett’s Esophagus
Barrett’s esophagus is a disorder of the esophagus (swallowing tube) in which the normal inner lining of the esophagus changes to resemble the lining of the stomach and the intestine (specialized intestinal metaplasia). This change is in response to chronic irritation from the reflux of gastric and small-bowel contents into the esophagus.
What are the symptoms of Barrett’s esophagus?
Barrett’s esophagus may not cause any symptoms. But most patients diagnosed with Barrett’s esophagus have a history of long-standing gastroesophageal reflux disease (GERD). Typical symptoms of GERD include:
- Heartburn – a burning sensation in the chest
- Regurgitation – the sensation of food or gastric acid backing up into the esophagus or throat
- Dysphagia – difficulty swallowing (Note: This symptom requires immediate attention.)
Who is at risk for developing Barrett’s esophagus?
Several conditions and factors are associated with an increased risk for developing Barrett’s esophagus.
- Heartburn or GERD – It’s estimated that 10% -15% of patients experiencing GERD symptoms two to three times per week have coexistent Barrett’s esophagus on endoscopy.
- Obesity – Obese patients, especially those with a body mass index (BMI) over 30, are 2.5 times more likely to develop Barrett’s compared to normal- weight patients.
- Gender – Men are four times more likely to develop Barrett’s esophagus than women.
- Ethnicity – Population-based studies in the United States indicate that the incidence of Barrett’s esophagus is up to fourfold higher in Caucasian patients compared to African American or His-panic patients.
- Increasing age – Starting at age 40, there appears to be a small but incremental increase in the risk of developing Barrett’s esophagus. Most patients with a new diagnosis are between the age of 50 and 60 years.
- Family history – Some studies have shown that up to 7% of patients with Barrett’s esophagus may have a similarly affected first-or second-degree relative. The exact risk for family members of patients with Barrett’s esophagus is still being defined.
What is the role of a hiatal hernia in Barrett’s esophagus?
Nearly all patients with Barrett’s esophagus have a hiatal hernia. A hiatal hernia predisposes a person to GERD due to the migration of part of the stomach through the diaphragmatic opening (hiatus) into the chest cavity, resulting in a loss of the “anti-reflux valve.” A large hiatal hernia may warrant surgical repair before embarking on treatment for Barrett’s esophagus.
What are the complications of Barrett’s esophagus?
Barrett’s esophagus is a premalignant condition and can lead to the development of esophagus cancer, known as adeno-carcinoma. Fortunately, the majority of patients with Barrett’s esophagus will not develop cancer and the rate of developing cancer is only about 0.5% each year. Cancer in Barrett’s esophagus generally develops in a stepwise fashion, starting with low-grade dysplasia and progressing to high-grade dysplasia and finally to cancer. With endoscopic surveillance of Barrett’s, it’s usually possible to detect the transformation toward cancer before cancer develops.
How is Barrett’s esophagus diagnosed?
Barrett’s esophagus can be easily diagnosed by routine upper endoscopy and confirmed on biopsies. But more challenging is the detection of precancerous and cancerous change in Barrett’s esophagus. Dysplasia and cancer may develop as “islands in a sea” of Barrett’s esophagus.
Advanced Imaging Technology
At California Pacific Medical Center’s Interventional Endoscopy Services (IES), we use advanced imaging technology to detect dysplasia and cancerous changes at the very earliest stage when treatment is most effective.
Optical “Zoom” and high- resolution endoscopy
Specialized endoscopes equipped with microchips that generate high-resolution images with optical magnification greatly enhance the tissue architecture and vascular pattern. This technology, in conjunction with other advanced imaging techniques such as narrow-band imaging (NBI) that use a selective reflective property of light, greatly enhance the detection of dysplasia and cancerous changes in Barrett’s mucosa. This technology is available in only a few centers in the world.
Endoscopic Ultrasound (EUS)
A miniaturized high-frequency ultrasound transducer probe enables the endoscopist to “see” into the wall of the esophagus. The probe uses sound waves to determine the depth of invasion of a precancerous or cancerous lesion with great accuracy. This information is critical in planning the most appropriate treatment.
What are the treatment options for Barrett’s esophagus?
At IES we use a multidisciplinary approach to Barrett’s esophagus. Patients will be counseled about treatment for GERD. If a large hiatal hernia is present, we may recommend surgical repair. Patients with dysplasia will be counseled about treatment options, including surveillance (watchful-waiting strategy). Most patients are interested in therapies to treat the dysplasia and remove Barrett’s esophagus. These will be discussed, and the risks and benefits will be detailed. We will tailor a treatment strategy specific for each patient. Treatment options include:
Endoscopic Mucosal Resection (EMR) or Mucosectomy
This procedure involves the removal or “stripping off” of abnormal tissue, using minimally invasive microsurgical techniques through the endoscope. The resected tissue is examined by the pathologist to ensure proper diagnosis and removal. Normal squamous tissue grows in place of the resected tissue.
Physicians at IESMG have been performing this procedure for many years with excellent results.
Radiofrequency Ablation (RFA)
Dysplastic cells in the esophagus can be treated with bursts of thermal energy to “burn” the abnormal lining. This is an outpatient procedure and the patient can expect to return to normal activities the next day. Some patients may experience chest discomfort for up to a week after treatment. In multicenter studies, RFA has been shown to completely eliminate dysplastic tissue in 80 % to 90% of the patients.
Cryotherapy
Similar to RFA, cryotherapy destroys abnormal cells by thermal extremes. Liquid carbon dioxide or nitrogen is delivered through the endoscope to “freeze” the abnormal lining. The treated tissue sloughs off and is replaced by normal esophageal tissue.