Definition

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 gastroesophageal reflux disease damages the squamous lining of the esophagus and the injury heals through a process called metaplasia, in which columnar cells replace squamous ones.

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.

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.

Causes

Gastroesophageal reflux disease is the main known risk factor for development of Barrett’s esophagus. The condition develops when gastroesophageal reflux disease damages the squamous lining of the esophagus and the injury heals through a process called metaplasia, in which columnar cells replace squamous ones. 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. This is extremely important in patients with Barrett’s esophagus since it is well known that 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.

Symptoms

Typical (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 gastroesophageal reflux 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.

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).

Surveillance

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 may progress 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. In addition, the development of high-grade dysplasia is associated with a significantly increased risk for adenocarcinoma.

Therefore, patients with Barrett's esophagus should be enrolled in an endoscopic surveillance program to watch for any progression of the Barrett's esophagus to cancer.

We advise our patients with Barrett’s esophagus to have yearly endoscopy, and we increase the frequency to every three to six months for patients with dysplasia (abnormal cells). The Practice Parameters Committee of the American College of Gastroenterology has recently suggested that surveillance may be extended to every two to three years in patients with Barrett’s esophagus without dysplasia. For patients with low-grade dysplasia, they recommend that surveillance endoscopy be performed at six-month intervals for the first year, and subsequently done once a year if there has been no change.

Treatment

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
By Michel Kafrouni, M.D.

Despite dietary and lifestyle changes, some patients still require medications to control their reflux symptoms. The medications can be given for a short period of time to help with the acute symptoms and to give time for the lifestyle and habits to change. However, some patients require lifetime treatment. Many medications have been used to control GERD. Proton pump inhibitors (PPIs) are the mainstay of treatment. They are potent acid reducers that block the pumps responsible for supplying the acid to the stomach. PPIs include omeprazole, lansoprazole, pantoprazole, esomeprazole and others. These medications are generally safe and can be taken once or twice per day (half an hour before breakfast or dinner).

Other medications have been used to treat GERD. Antacids neutralize the acidity of the stomach and provide short-term relief. Other medications, such as sucralfate, provide a barrier that lines the esophageal and stomach mucosa and protects it from the gastric juices, thus providing the time needed to heal. Some antihistamines, such as ranitidine and famotidine, also can be used to decrease the secretion of acid into the stomach lumen.

Most commonly, the refluxed gastric contents are acidic, and typical medical therapy for reflux aims to suppress gastric acidity. However, bile (non-acidic fluid) may also be present within the gastric juice that is refluxed up 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 reflux. This is extremely important in patients with Barrett’s esophagus, since it is well known that bile causes injury to the lining of the esophagus and is a risk factor for developing Barrett’s esophagus.

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

This endoscopic technique 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 the Memorial Hermann Southeast Esophageal Disease Center for the treatment of patients with gastroesophageal reflux disease and Barrett’s esophagus. This procedure can be performed in combination with endoscopic ablation in selected patients.