Barrett’s Esophagus: Feeling The Burn?
Barrett’s Esophagus is a GI disease process that is not too well known, however more patients than ever are being diagnosed. You may have recently had an endoscopy and your doctor mentioned in the results that you have Barrett’s Esophagus, or you were possibly even referred for a screening endoscopy due to long-standing heartburn and reflux disease. So what does it all mean?
First we need to define Barrett’s Esophagus in order to understand it. Chronic reflux of contents from the stomach to Esophagus over time may cause changes to the lining of the Esophagus. On an Endoscopy this may be visible as a “salmon-colored” lining, and on biopsy cells that are more similar to Intestinal lining are noted - this is the defining characteristic of Barrett’s Esophagus. .
What are the symptoms that tell me I may have Barrett’s Esophagus?
Unfortunately there are no specific symptoms. It is sometimes a consequence of chronic ongoing reflux disease, and as such patients with longstanding untreated reflux and/or heartburn may benefit from an endoscopic screening depending on their demographic (Caucasian males appear to be the highest risk demographic).
What are the long-term risks?
Long-term, we worry about cancer development as the Intestinal-type lining is not native to the esophagus, and is more sensitive to further injury from acid exposure. An important point to keep in mind – the annual risk of cancer progression is still low on average, and recent studies in the last few years have suggested that it may even be slightly less than previously thought.
What can I do to prevent Barrett’s Esophagus, and if I have it, to prevent the progression to cancer?
Identification is key. If you have been suffering with untreated heartburn and/or reflux for some time, it is worth a consultation with your gastroenterologist. For the majority, the development of Barrett’s seems tied to the chronic irritation from reflux events, and therefore it stands to reason that if you address the reflux, your risk for Barrett’s decreases. In a similar thought, patients with limited or uncomplicated Barrett’s changes should be taking PPI therapy (medications such as Protonix, Nexium, etc) to prevent further changes, and consider surgical intervention for patients who have symptoms unresponsive to medication.
It is important to note that cancer in the setting of Barrett’s Esophagus does not develop without other changes along the way. In order to better understand this, we need to know a few terms related to the Barrett’s first so that we can identify those patients with more advanced disease who would benefit from more aggressive intervention. Active treatments, both endoscopic and surgical, are typically reserved for patients with more advanced disease.
Intestinal Metaplasia – This is the earliest form of Barrett’s, when the lining simply appears similar to Intestine to the pathologist on the biopsy specimens.
Intestinal Metaplasia with Dysplasia – This is when the first changes are being noticed. Cancer is not seen on the samples, but there is a disordered-appearance to the cells. These can usually be subcategorized into low and high-grade (“less or more”) dysplasia. At this point the annual risk for progression to cancer is increasing.
Carcinoma – This is the pathological terminology for the presence of Cancer.
To summarize this concept another way:
Metaplasia ---> Dysplasia ----> Carcinoma
What are the options available for patients with more advanced disease?
Low grade and high grade dysplasia patients are nowadays best served by endoscopic therapy, with the goal of eradicating the Barrett’s tissue. Some patients without dysplasia may benefit as well depending on clinical circumstance and this is a discussion to have with your gastroenterologist. Options include Radiofrequency Ablation (“Hot”) or Cryotherapy Ablation (“Cold”) with more aggressive removal of areas that are irregular or bumpy which is called Endoscopic Mucosal Resection. Research has not shown either of these treatments to be superior to the other, but in the North Texas area, it is more common to find doctors performing Radiofrequency Ablations (RFA). If you are offered either of these therapies, you may undergo treatment over a few sessions with aggressive surveillance afterwards in order to make sure the area has been adequately treated and there is no residual/recurrent disease.
For patients where the biopsies already show cancer, it depends on how advanced the cancer is. If if it still small and local, limited resection and ablation by your gastroenterologist may be an option, with surgery, chemotherapy, and radiation strategies reserved for patient with more than the most limited disease.
With the development of antacid therapy, surgical intervention for GERD, development of screening strategies, coupled with widespread availability of RFA and Cryotherapy, gastroenterologists nowadays are identifying patients more regularly and at earlier stages of disease. This allows us to intervene early, and identify those patients who may benefit from more aggressive surveillance and treatment.
Current Guidelines for evaluation and treatment of Barrett's Esophagus per the American College of Gastroenterology can be found here