Barrett’s oesophagus

• What is Barrett’s Oesophagus?
• Statistics
• Risk Factors
• Progression
• Symptoms
• Clinical Examination
• How is it Diagnosed
• Treatment
• References

What is Barrett’s Oesophagus?

Barrett’s oesophagus is a complication of gastro-oesophageal reflux disease (GORD). Barrett’s oesophagus develops when the cells of the lower oesophagus are damaged through continuous exposure to stomach acid and undergo a change (‘metaplasia’) to a different cell type. This places the individual at increased risk of developing oesophageal cancer.
The image below shows an endoscopic view of an ulcerated oesophagus. This is part of the disease process leading to Barrett’s oesophagus.

Statistics

Barrett’s oesophagus is classified into short-segment (< 3 cm) and long-segment (> 3 cm) disease, according to the length of oesophagus that is affected. Short-segment disease is thought to be present in as many as 15% of the population, while long-segment disease probably only affects about 0.5%.
Barrett’s oesophagus affects men about twice as often as women. The risk of developing disease increases with age, with an average age at diagnosis of 60 years. Middle-aged men are the most commonly affected group.
In general, the longer the duration of GORD, the greater the risk of developing Barrett’s oesophagus.

Risk Factors

The major predisposing factor for development of Barrett’s oesophagus is a history of chronic gastroesophageal reflux disease. Smoking and excessive alcohol consumption may also increase your risk.
A family history of either gastroesophageal reflux disease or Barrett’s oesophagus may predispose someone to development of the disease.
Some studies have suggested that people with coeliac disease or systemic scleroderma may be at increased risk of developing Barrett’s oesophagus. However the exact risks of these conditions is not known.

Progression

The major risk of Barrett’s oesophagus is that the condition may progress to cancer of the oesophagus. This occurs at a rate of 0.5% per year; meaning that if 200 patients are identified as having Barrett’s oesophagus, one patient in that group would be expected to develop oesophageal adenocarcinoma each year. Other complications of Barrett’s oesophagus include ulceration of the oesophagus and development of strictures. This can lead to difficulties with swallowing.
Once the metaplasia (cell change) of Barrett’s oesophagus has occurred, it is virtually impossible to reverse the process. Treatment with antacid medications or surgery generally does not lead to regression. This means that regular surveillance of patients with significant (> 3 cm) metaplastic change is important to ensure that any pre-cancerous changes are detected early.

Symptoms

Patients with Barrett’s oesophagus usually have a history of gastro-oesophageal reflux disease. Symptoms of reflux disease include:

• Heartburn (a burning discomfort in the upper abdomen or behind the breastbone, worsened by eating or lying down);
• An unpleasant or sour taste in the mouth;
• Over-production of saliva (water brash); or
• Chronic dry cough.

Sometimes, patients might first notice symptoms from complications of Barrett’s oesophagus, including difficulty swallowing from formation of strictures (tight bands) across the oesophagus.
When you see your doctor they will ask several questions about these symptoms, paying particular attention to their severity and duration. They may also ask about any family history of GORD or Barrett’s oesophagus.

Clinical Examination

Your doctor cannot diagnose Barrett’s oesophagus based on physical examination. The diagnosis is made based on the classic symptoms of GORD for a reasonable duration, followed by further investigations.

How is it Diagnosed

The diagnosis of Barrett’s oesophagus requires an endoscopy. A long flexible tube is passed through the mouth into the oesophagus and stomach so that the physician can look at the lining of these organs. Usually, a small sample of the tissue (a biopsy) will be taken during the endoscopy, and examined under a microscope to identify any changes in the cells.

Treatment

Because Barrett’s oesophagus is thought to develop after long-term acid damage to the oesophagus, an important principle of treatment is to prevent further acid damage. Some lifestyle changes, such as weight reduction and avoidance of alcohol, caffeine and fatty foods, may help. Proton pump inhibitor medications such as omeprazole are also very useful. Most of these methods, however, are for symptomatic relief and do not necessarily halt the progression of Barrett’s oesophagus.
Most patients with Barrett’s oesophagus will also undergo some kind of regular endoscopic monitoring to catch any early, pre-cancerous (dysplastic) changes. There is currently some disagreement about how often patients should be monitored. This is because endoscopies are not without risks, are costly and may not always be able to pick up any changes that are present.
Treatment options for dysplastic changes, once identified, are also limited. Some of the treatment options currently available include:

• Endoscopic ablative therapy: In this treatment, the abnormal tissue in the oesophagus is burnt or chemically damaged. New, healthy tissue should then grow to cover the damaged area;
• Photodynamic therapy: This technique also aims to kill the abnormal cells in the oesophagus, but uses laser energy and special photosensitising chemical agents to achieve the same effects. Complications may include development of scarring and strictures;
• Oesophagectomy: This is a surgical procedure to remove part of the oesophagus. It is the only way to completely remove pre-cancerous or cancerous tissues, but it carries a number of risks, including a 5-10% chance that the patient will not survive the operation.

You should discuss treatment options with your doctor. They are able to consider the best treatment for you based on the severity and features of your individual disease.

References

1. Bonino JA, Sharma P. Barrett’s esophagus. Curr Opin Gastroenterol. 2006;22(4):406-11. [Abstract]
2. Braunwald E, Fauci AS, Kasper DL, et al. Harrison’s Principles of Internal Medicine (16th edition). New York, NY: McGraw-Hill Publishing; 2005. [Book]
3. Burkitt HG, Quick CRG. Essential Surgery: Problems, diagnosis and management (3rd edition). London: Churchill Livingstone; 2002. [Book]
4. Cotran RS, Kumar V, Collins T, Robbins SL. Robbins Pathologic Basis of Disease (6th edition). Philadelphia, PA: WB Saunders Company; 1999. [Book]
5. DeVault KR, Castell DO. Updated guidelines for the diagnosis and treatment of gastroesophageal reflux disease. Am J Gastroenterol. 2005;100(1):190-200. [Abstract]
6. Faybush EM, Sampliner RE. Randomized trials in the treatment of Barrett’s esophagus. Dis Esophagus. 2005;18(5):291-7. [Abstract]
7. Kumar P, Clark M (eds). Clinical Medicine (5th edition). Edinburgh: WB Saunders Company; 2002. [Book]
8. Lane M. Barrett’s oesophagus. Curr Ther. 2002;43(2):51-5. [Abstract]
9. Srinivas N. Barrett’s esophagus imaging [online]. Omaha, NE: eMedicine; 2005 [cited 30 August 2006]. Available from: URL link