What is Barrett's Esophagus?
Why does Barrett's esophagus develop?
Who gets Barrett's esophagus?
What are the symptoms of Barrett's esophagus?
How do I know if I have Barrett's esophagus?
Why is it important to know if I have Barrett's esophagus?
What is the risk of cancer in Barrett's esophagus?
How is Barrett's esophagus treated?
What if I have dysplasia?
The esophagus is a muscular tube that extends from the neck to the abdomen and connects the back of the throat to the stomach. Its inner lining, or mucosa, normally consists of flat cells (known as squamous cells) that are similar to those of the skin. When this squamous cell lining is replaced by other cells that have a more cube-like shape, the condition is known as Barrett's esophagus or the columnar-lined esophagus, referring to cells that are shaped like a column. When Barrett's esophagus is present, the columnar lining extends from the junction of the esophagus and stomach upwards into the esophagus for a variable distance ranging from a few millimeters to nearly the entire length of the esophagus.
When the normal squamous lining cells of the esophagus are replaced by columnar cells, the process is known as metaplasia. Barrett's esophagus is a form of metaplasia. The metaplastic columnar lining comes in three types. Two types are similar to groups of cells found in regions of the stomach lining. The third type is similar to groups of cells found in the small intestine. This intestinal type of metaplasia is important because it can potentially lead to the development of cancer.
The exact reasons for the development of Barrett's esophagus are unknown. The most widely accepted theory is that damage to the squamous mucosa initiates a process of healing. There are cells lying deep in the wall of the esophagus that have the potential to transform themselves into a variety of shapes and take on special functions during this healing process. It is these cells that become the new columnar mucosa of the esophagus.
Most physicians believe that the damage to the squamous mucosa which leads to the development of Barrett's esophagus is caused by chronic reflux of acid or other stomach contents into the esophagus. It is likely that some people are predisposed to develop Barrett's esophagus based on their genetic make-up.
Physicians believe that most people who have Barrett's esophagus have a problem of chronic reflux of acid into the esophagus, which typically causes symptoms of heartburn. It is thought that 10 to 20 million people in the U.S. have acid reflux problems. Most of those people don't require special treatment for this condition. People who have severe reflux problems are more likely to have Barrett's esophagus. It is thought that up to 1 out of 10 people with severe reflux problems have Barrett's esophagus.
Barrett's esophagus usually doesn't produce any specific symptoms on its own. People with chronic acid reflux problems may experience a variety of symptoms including heartburn, regurgitation of food, swallowing difficulties, excess belching, hoarseness, sore throat, cough, or breathing problems similar to asthma such as shortness of breath and wheezing. The columnar lining may become irritated and bleed, resulting in anemia (low blood count), or may develop ulcerations which cause pain, but these problems aren't common.
Because Barrett's mucosa produces no specific symptoms, the only way of knowing for certain whether you have Barrett's esophagus is to undergo upper gastrointestinal endoscopy. During this outpatient examination, which is performed under sedation, a flexible telescope is passed through your mouth, down your esophagus, and into your stomach, permitting the physician performing the test to view the lining surfaces of the esophagus and stomach. Barrett's mucosa is recognized by its characteristic red appearance, which stands out in contrast to the pale appearance of the squamous mucosa. A small bite, or biopsy, of tissue measuring 1 or 2 mm permits microscopic examination, which is necessary to confirm the existence of Barrett's mucosa.
The main reason that it's useful to know whether you have Barrett's esophagus is that this is a premalignant condition, meaning that patients with Barrett's esophagus have a higher-than-average risk of getting cancer. Cancers can arise from regions of Barrett's mucosa containing intestinal metaplasia. The abnormal mucosa degenerates into a premalignant phase known as dysplasia. In some patients this dysplastic mucosa will further degenerate in a step-wise process from low-grade dysplasia into high-grade dysplasia and then cancer, often during an interval of several years. If you have Barrett's esophagus it's important that you consult with your physician about endoscopy to evaluate for the risk or existence of cancer. Patients with Barrett's esophagus should have endoscopy performed every 1 to 3 years, a practice known as surveillance endoscopy.
The exact risk of a patient with Barrett's esophagus developing cancer is not known. Current estimates put the risk at 40 times higher than in the normal. Although the risk of cancer is increased, the actual chance of getting a cancer is quite small. Out of a population of 1 to 2 million people with Barrett's esophagus, annually between 10,000 and 15,000 people in the U.S. get the type of cancer associated with Barrett's esophagus.
There is no need for routine treatment for Barrett's esophagus. Most people who have Barrett's esophagus have heartburn or other symptoms of acid reflux and take antacids or some type of medication to suppress the production of stomach acid. These medications provide relief from reflux symptoms but don't have any important effects on the Barrett's mucosa. As far as we can tell, there is no easy way to cause the Barrett's mucosa to disappear, nor is there any easy way to prevent the development of cancer in a patient with Barrett's mucosa. There is growing evidence that successful surgical antireflux therapy may help prevent the development of cancer in Barrett's esophagus, but this is controversial.
Some physicians are experimentally trying to destroy the Barrett's mucosa with the hope that normal squamous mucosa will grow back. The current results are promising but the procedures should be performed as part of an investigational study by a highly experienced physician. Whether this concept will prove feasible for long-term management of Barrett's esophagus awaits further trials in large numbers of patients.
Whether dysplasia exists is difficult to determine except by an expert pathologist. If biopsies suggest dysplasia, repeat biopsies often are performed and the tissue is sometimes sent to a pathologist with a lot of experience interpreting biopsies from patients with Barrett's esophagus. Low-grade dysplasia requires no specific therapy. An increase in the frequency of surveillance endoscopy is usually recommended for patients with low-grade dysplasia because of the further increase in risk of degeneration into cancer.
If the presence of high-grade dysplasia is confirmed, the appropriate management is controversial. Some physicians will recommend close surveillance with endoscopy every 3 to 6 months. Mucosal destruction combined with intense acid suppression is being used experimentally to reduce the risk of cancer.
For most patients with high-grade dysplasia the appropriate recommendation is to have the esophagus removed. This is because in up to 50% of patients who have high-grade dysplasia identified on endoscopic biopsy the results of surgery actually show an unsuspected invasive cancer. The results of surgical therapy for an esophageal cancer identified in this setting are quite good.