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Barrett's Esophagus

Barrett’s esophagus is a change in the normal lining of the esophagus (squamous mucosa) to a lining similar to the lining of the stomach (columnar mucosa) that is visible by endoscopy. In patients with Barrett’s esophagus, biopsy of the lining of the esophagus shows evidence of intestinal metaplasia: replacement of one cell type (squamous) with a different cell type (columnar).

Presence of cells called “goblet cells,” which are indicative of intestinal metaplasia in the biopsy specimen, is necessary to diagnose Barrett’s esophagus.

The condition develops when GERD damages the squamous lining of the esophagus and the injury heals through a process called metaplasia, in which columnar cells replace squamous ones.

History of Barrett’s Esophagus

Barrett’s esophagus is named after the British surgeon Norman Barrett, who in 1950 identified the changes in the lining of the esophagus, but thought they were congenital (present at birth). In 1970, it was shown that Barrett’s esophagus is an acquired condition (presents later in life). It is known that Barrett’s esophagus develops in approximately 5 to 8 percent of patients with gastroesophageal reflux disease.

Disease Progression

With continued irritation of the metaplastic epithelium (lining of the esophagus) caused by gastroesophageal reflux disease, some patients will progress to further cellular damage. These changes happen in a sequence, and the damage to the cells progresses to low-grade dysplasia (abnormal cells), which then transform to high-grade dysplasia (precancerous cells), and finally to invasive adenocarcinoma, which can develop in approximately 0.5 percent per year in patients with Barrett's esophagus.

Barrett's Esophagus Causes & Symptoms

Increased Risk

The risk is increased in patients who reflux both stomach acid and bile (non-acidic fluid) into the esophagus. Neutralization of acid with antacid medications does not prevent injury to the esophagus from the non-acidic fluid. Therefore, even with suppression of acid production and decrease or elimination of heartburn with medical therapy, damage to the lining of the esophagus may continue in patients with bile (non-acidic fluid) reflux.

Bile causes injury to the lining of the esophagus and is a risk factor for developing Barrett’s esophagus. Anyone with long-standing (five or more years) reflux symptoms is at risk to have or develop Barrett's esophagus.

Causes

GERD is the main known risk factor for development of Barrett’s esophagus. The condition develops when GERD damages the squamous lining of the esophagus and the injury heals through a process called metaplasia, in which columnar cells replace squamous ones.

Symptoms

Common symptoms

  • Heartburn (burning sensation behind the breast bone)
  • Epigastric pain (upper abdominal pain)
  • Dysphagia (difficulty swallowing or the sensation that food is hanging up or not passing down into the stomach properly)
  • Regurgitation of food or liquids, particularly when bending over or laying down, associated with a bitter taste in the mouth

Atypical (uncommon) symptoms

  • Chest pain
  • Hoarseness
  • Cough
  • Pneumonia

The lining of the esophagus in patients with Barrett’s seems to be less sensitive to acid. Patients may notice an improvement in their reflux symptoms with the development of Barrett's esophagus, but the injury to the lining of the esophagus continues if the GERD is not treated. Any dysphagia (difficulty swallowing) in association with reflux symptoms is concerning and further assessment should be done to look for a stricture or tumor in the esophagus.

Barrett's Esophagus Diagnosis

Upper endoscopy with biopsy is the main diagnostic study. Endoscopy in a patient with Barrett's esophagus shows that the normal pale-white squamous mucosa of the lining of the esophagus has changed to a reddish (salmon color), columnar mucosa, similar to the lining of the stomach (see image below).

In patients with Barrett’s esophagus, a biopsy shows intestinal metaplasia, a change in the normal lining of the esophagus (squamous mucosa) to a lining similar to the that of the stomach (columnar mucosa), with the presence of goblet cells (see image below).

Barrett's Esophagus Treatment

Because of the connection between Barrett's esophagus and esophageal cancer, it is crucial that patients with Barrett's Esophagus see a gastroenterologist on a regular basis for endoscopic surveillance.

Long-standing gastroesophageal reflux disease (GERD) is a major cause of Barrett’s esophagus. Thus controlling GERD is the main step in the management of Barrett’s esophagus. Medical treatment is often effective. Endoscopic and surgical treatment can also be called for.

At Memorial Hermann, patients with Barrett's esophagus receive multidisciplinary care from expert gastroenterologists, pathologists, radiologists, oncologists and surgeons. Our team will recommend important lifestyle changes that will reduce acid reflux symptoms and lessen the likelihood of cancer, as well as prescribe necessary medications and discuss surgical treatment if necessary. Our state-of-the-art treatments include:

Endoscopic Treatment

Radiofrequency ablation

Endoscopic ablation techniques use thermal destruction of the abnormal lining cells in the esophagus and are used in patients when Barrett’s esophagus with low-grade dysplasia (abnormal cells) and high-grade dysplasia (precancerous cells). Heat is applied under control via a small balloon during an upper endoscopy, allowing the abnormal cells to be eliminated and the normal esophageal lining to grow back.

Endoscopic mucosal resection

Endoscopic mucosal resection is used in patients who have Barrett’s esophagus with small areas of high-grade dysplasia (precancerous cells), or superficial cancer in the esophagus. With this technique, the part of the lining of the esophagus which contains the abnormal or cancerous cells is removed.

Surgical Treatment

The aim of surgical treatment is to restore the function of the lower esophageal sphincter (the valve between the esophagus and the stomach) to prevent the reflux of acid and bile (non-acidic fluid) from the stomach into the esophagus and prevent further injury to the esophageal lining.

The most common procedure to restore the function of the lower esophageal sphincter and prevent reflux of acid and bile is a minimally invasive procedure called laparoscopic Nissen fundoplication and is routinely performed at Memorial Hermann. This procedure can be performed in combination with endoscopic ablation in selected patients.

By Farzaneh Banki, M.D.

References 

1. Provenzale D, Kemp JA, Arora S, Wong JB. A guide for surveillance of patients with Barrett’s esophagus. Am J Gastroenterol 1994; 89:670–680.
2. Sampliner RE. Practice guidelines on the diagnosis, surveillance, and therapy of Barrett’s esophagus. The Practice Parameters Committee of the American College of Gastroenterology. Am J Gastroenterol 1998; 93:1028 –1032.
3. Steven R DeMeester and Tom R DeMeester, Columnar mucosa and intestinal metaplasia of the esophagus. Annals of Surg 2000;231:3:303-321
4. Shaheen N, Ransohoff DF. Gastroesophageal reflux, Barrett esophagus, and esophageal cancer: scientific review. JAMA 2002; 287:1972-81.