Ohio GI [Barrett's Esophagus]

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INTRODUCTION The esophagus is the tube that connects the mouth with the stomach ( show figure 1 ). Barrett's esophagus occurs when the normal cells that line the lower part of the esophagus (called squamous cells) are replaced by a different cell type (called intestinal cells). This process usually occurs as a result of repetitive damage to the inside of the esophagus.

The most common cause of Barrett's esophagus is longstanding acid reflux disease, called gastroesophageal reflux disease (GERD). In people with GERD, the esophagus is repeatedly exposed to excessive amounts of stomach acid. Interestingly, the intestinal cells of Barrett's esophagus are more resistant to acid than squamous cells, suggesting that these cell may develop to protect the esophagus from acid exposure. The problem with Barrett's esophagus is that the intestinal cells have a risk of transforming into cancer cells.

RISK FACTORS There are a number of factors that increase the risk of developing Barrett's esophagus:

Age Barrett's esophagus is most commonly diagnosed in middle-aged and older adults; the average age at diagnosis is 55 years. Children can develop Barrett's esophagus, but rarely before the age of 5 years.

Gender Men are more commonly diagnosed with Barrett's esophagus than women.

Ethnic background Barrett's esophagus is equally common in white and Hispanic populations and is uncommon in black and Asian populations.

Lifestyle Smokers are more commonly diagnosed with Barrett's esophagus than nonsmokers.

SYMPTOMS Barrett's esophagus itself produces no symptoms. Instead, most people seek help because of symptoms of GERD, including heartburn, regurgitation of stomach contents, and, less commonly, difficulty swallowing.

DIAGNOSIS A healthcare provider may suspect Barrett's esophagus based upon a person's symptoms and the risk factors described above. An endoscopy is needed to confirm the abnormal esophageal lining.

Upper endoscopy Before upper endoscopy, the patient is sedated with medication to prevent discomfort. A physician inserts a thin lighted tube into the patient's esophagus. The tube has a camera, which allows the physician to see the lining of the esophagus. Normally, the lining should appear pale and glossy; in a person with Barrett's esophagus, the lining appears pink or red and velvety ( show picture 1 ). A small sample of the lining is removed during the endoscopy to examine it with a microscope. ( See "Patient information: Upper endoscopy" ).

Endoscopy detects most (80 percent) but not all cases of Barrett's esophagus. Individual variations in the anatomy of the esophagus and its junction with the stomach can make the diagnosis of Barrett's esophagus difficult in some people ( show figure 2 ).

TREATMENT

Behavior and diet changes The first priority in treating Barrett's esophagus is to stop the damage to the esophageal lining, which usually means eliminating acid reflux. Most patients are advised to avoid certain foods and behaviors that increase the risk of reflux. Foods that can worsen reflux include:

Chocolate
Coffee and tea
Peppermint
Alcohol
Fatty foods

Acidic juices such as orange or tomato juice may also worsen symptoms. Carbonated beverages can be a problem for some people. ( See "Patient information: Gastroesophageal reflux disease in adults" ).

Behaviors that can worsen reflux include eating meals just before going to bed, lying down after eating meals, and eating very large meals. Placing bricks or blocks under the head of the bed (to raise it by about six inches) help to keep acid in the stomach while sleeping. It is not helpful to use additional pillows under the head.

Medications A clinician may prescribe medications that reduce the amount of acid produced by the stomach. A class of medications called proton pump inhibitors are commonly recommended. Five different formulations of these drugs are currently available: omeprazole (Prilosecÿ), esomeprazole ( Nexiumÿ), lansoprazole (Prevacidÿ), rabeprazole (Aciphexÿ) and pantoprazole (Protonixÿ); any of these is an acceptable option.

Surgery Patients who have severe reflux may benefit from surgical procedures to reduce reflux. Surgery is not the best treatment in all situations, so patients should discuss this option with their clinician. More information about surgical treatments for reflux is available in a separate topic review. ( See "Patient information: Gastroesophageal reflux disease in adults" ).

COMPLICATIONS One potential complication of Barrett's esophagus is that, over time, the abnormal esophageal lining can develop early precancerous changes. The early changes may progress to advanced precancerous changes, and finally to frank esophageal cancer. If undetected, this cancer can spread and invade surrounding tissues.

However, progression to cancer is uncommon; studies that follow patients with Barrett's esophagus reveal that only 0.5 percent of patients develop esophageal cancer per year. Furthermore, patients with Barrett's esophagus appear to live just as long as people who are free of this condition. Patients often die of other causes before Barrett's esophagus progresses to cancer.

MONITORING

Endoscopy Monitoring for precancerous changes is recommended for most patients with Barrett's esophagus. At this time, monitoring includes periodic endoscopy with tissue biopsy. ( See "Patient information: Upper endoscopy" ).

Although new technologies are on the horizon, most are still considered to be experimental. Experts do not agree about the usefulness of monitoring. The relative benefits of monitoring depend upon each patient's chance of developing esophageal cancer, which may be difficult to determine.

Benefits Reasons to perform endoscoping monitoring include:

Monitoring can detect precancerous changes (dysplasia) in the esophageal lining. These changes may indicate that the person has an increased risk of cancer. Early detection may be especially important for younger patients.

Monitoring may detect cancer at an earlier stage, when it can be more effectively treated.

Limitations However, not all patients will benefit from endoscopic monitoring.

Progression of Barrett's esophagus to cancer is uncommon.

Endoscopy carries certain risks and often causes needless worry.

Endoscopy may miss areas with premalignant changes or cancer.

Even if endoscopy detects cancer, the available treatment options may have unacceptably high risks.

ADVANCED PRECANCEROUS CHANGES

Confirmation and staging If precancerous changes are discovered, they should be confirmed with a second opinion. It is sometimes difficult to correctly identify precancerous changes, especially when there is inflammation (usually caused by the ongoing reflux of acid). Many clinicians increase the dose of acid-suppressing medications in this situation.

The precancerous changes must then be graded as "low grade dysplasia" or "high grade dysplasia," depending upon their severity. Patients with low grade dysplasia are usually told to increase their dose of acid suppressing medication and undergo a repeat endoscopy in a few months.

A patient with high grade dysplasia has more limited options. With this type of precancerous change, there is a higher risk for developing cancer, and the person may already have it. Thus, many doctors recommend surgically removing the esophagus (esophagectomy), although this recommendation is somewhat controversial. Another option (photodynamic therapy) is available for patients enrolled in a clinical trial at some specialized centers.

Esophagectomy Reasons to remove the esophagus (esophagectomy) include:

Cancer is already present in approximately one-third of patients with advanced premalignant changes (high grade dysplasia).

Not removing the esophagus would mean that the person would need frequent monitoring with endoscopy and numerous biopsies.

Once Barrett's esophagus has progressed to an advanced premalignant state, further progression to cancer is common and may occur rapidly.

It is not known if endoscopy can detect cancer while it is still curable. This is the goal of a preventive test, and would improve a person's chances of surviving.

Esophageal cancer that begins to invade other tissue may be incurable.

However, esophagectomy may not be necessary in all patients. In addition, the surgery has some serious risks.

Advanced premalignant changes do not always progress to esophageal cancer. Studies suggest that progression to cancer occurs in 18 to 43 percent of patients.

Advanced premalignant changes may actually regress in some patients.

Vigilant endoscopic monitoring can be used to detect early cancer.

Esophagectomy has a 5 to 10 percent chance of leading to death.

Esophagectomy can have other serious complications that decrease quality of life.

Photodynamic therapy Photodynamic therapy a treatment that uses chemical agents, known as photosensitizers, to kill certain types of cells (such as Barrett's cells) when the cells are exposed to a specific type of light. Patients are given the photosensitizer medication into a vein and then undergo endoscopy. During the endoscopy, a laser light is used to activate the photosensitizer and destroy the Barrett's tissue.

However, there is limited information on the long-term outcome of this approach. Furthermore, photodynamic therapy is expensive, available in only a small number of academic medical centers. In up to 40 percent of patients, the procedure causes a complication, such as narrowing of the esophagus, which may require repeated treatments to open the esophagus.

Another concern with photodynamic therapy is that patients with high-grade dysplasia may have areas of invasive cancer that are not treated adequately. Thus, photodynamic therapy may be considered for patients with high-grade dysplasia who are not healthy enough to undergo surgical removal of the esophagus. In all cases, the patient and his or her family should discuss the risks and benefits of possible treatments with a healthcare provider.

ONGOING RESEARCH Research about Barrett's esophagus is focused on improving detection of the condition, including precancerous changes, and on developing better treatments.

Methods to improve detection Most of the methods being developed to improve detection involve changes to standard endoscopy. These include chromoendoscopy (using special dyes to highlight suspicious areas), magnification endoscopy (using high magnification), endoscopic ultrasound (using ultrasound waves), optical coherence tomography (using specialized optical equipment), and fluorescence detection techniques (using fluorescent dyes). None has yet been proven to work any better than standard endoscopic surveillance.

New treatments Several researchers have discovered that it may be possible to restore the normal esophageal lining (squamous cells) in patients with Barrett's esophagus by first destroying the Barrett's lining. Many techniques for destroying the Barrett's lining have been studied, including lasers, cautery, and combination therapy with chemicals and lasers. As of yet, it is not clear which patients would benefit from these approaches, particularly since they may be associated with side-effects (such as narrowing of the esophagus or creation of a hole in the esophagus during treatment).

The uncertainty about when to use these approaches is even greater given that the majority of patients with Barrett's will not develop precancerous changes. In addition, the techniques are very expensive. Furthermore, even in patients whose Barrett's tissue is destroyed with treatment, some Barrett's tissue may remain in the esophagus, which still has the potential to progress to dysplasia and cancer. For these reasons, these techniques should be considered experimental.

SUMMARY Despite the uncertainties surrounding the monitoring and treatment of Barrett's esophagus, there is consensus on one matter: The available options should be tailored to each patient. The following are general guidelines for patients:

Patients with Barrett's esophagus should be treated to decrease acid reflux into the esophagus. This may improve or eliminate symptoms of heartburn, reduce inflammation, help prevent complications, and improve the accuracy of endoscopy results.

Patients without evidence of precancerous changes (ie, no dysplasia) or esophageal cancer should have endoscopy with biopsies every 2 to 3 years (according to guidelines from major medical societies), unless there are other medical conditions that increase the small risks associated with endoscopy.

If endoscopy reveals a precancerous change (dysplasia), this finding should be confirmed by at least one expert; if necessary, additional tissue samples should be collected to resolve any doubt.

Patients with early precancerous changes (low grade dysplasia) should have repeat endoscopy at 6 and 12 months, followed by annual endoscopy if the lesion does not appear to progress.

Patients with advanced precancerous changes (high grade dysplasia) confirmed by an expert should choose between two options: endoscopic monitoring for cancer at three month intervals or surgical removal of the affected region of the esophagus. Photodynamic therapy may offer a third alternative.