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Barrett’s Esophagus

WHAT IS BARRETT’S?

When a patient develops Barrett’s Esophagus, the cells lining the esophagus (the tube connecting the mouth and stomach) changes to a type of cell that is more resistant to acid damage, similar to cells lining the stomach or intestinal lining. This cell change is called intestinal metaplasia.

People with Barrett’s Esophagus have a rare chance of developing cancer of the esophagus – this risk is considered to be about 0.2% per year.  Before cancer develops, the cells within Barrett’s Esophagus develop changes in appearance visible under the microscope, a change termed dysplasia.  When dysplasia becomes pronounced or ‘high grade’, chance of developing cancer increases to about 6% per year.  Therefore, periodic biopsies are taken from Barrett’s Esophagus to make sure dysplasia has not developed.

WHAT CAUSES BARRETT’S ESOPHAGUS?

The exact cause of Barrett’s Esophagus is unknown. Gastroesophageal reflux disease (GERD) is linked to the development of Barrett’s Esophagus because injury to the esophagus cells by stomach acid is an essential part in the formation of Barrett’s Esophagus. Between 5% and 10% of people with GERD develop Barrett’s Esophagus, most often in those who developed GERD at a young age or who have had symptoms of GERD for many years.

Barrett’s Esophagus is usually diagnosed in adults older than 50 years of age. Men are twice as likely to develop Barrett’s Esophagus as women.

HOW IS BARRETT’S ESOPHAGUS DIAGNOSED?

Endoscopy can help a gastroenterologist diagnose Barrett’s Esophagus. The parts of the esophagus with Barrett’s appear different from healthy tissue and may be visible to the doctor during endoscopy.  However, the mere appearance of different appearing lining is not enough to make a diagnosis of Barrett’s Esophagus.

A biopsy (tissue sample) is essential for a diagnosis of Barrett’s Esophagus.  Biopsies are taken with tissue forceps during endoscopy, and are not felt by the patient. Biopsies are also essential to look for dysplasia (cells changing appearance) that is not visible during endoscopy.

BARRETT’S ESOPHAGUS MANAGEMENT

If a patient’s biopsies taken during endoscopy show no dysplasia, GERD symptom management and monitoring the tissue affected by Barrett’s Esophagus is the only treatment needed. How often an endoscopy is needed also depends on whether dysplasia is present on biopsies. If no dysplasia is seen, endoscopy and biopsies every 3 to 5 years will suffice.

The gastroenterologist will also prescribe acid lowering medications for continued treatment for GERD symptoms.

If a patient’s biopsies taken during endoscopy show dysplasia, further endoscopy is needed based on whether the dysplasia is low grade (minor changes) or high grade (major changes).  With low grade dysplasia, endoscopy and biopsies are repeated at 6-12 month intervals till it is clear that the low grade dysplasia is stable, after which biopsies are taken every 1-2 years. 

If the biopsies show high grade dysplasia, several options are available.

First, the gastroenterologist can burn off or remove the area with high grade dysplasia. This can be done through several techniques, all involving advanced endoscopy:

Alternatively, the patient can be referred to a surgeon to remove the entire esophageal segment with Barrett’s esophagus. This used to be the main form of treatment of Barrett’s Esophagus until the above endoscopic techniques were developed.

Finally, some patients with serious medical conditions may not be able to tolerate these treatments.  Since most patients with high grade dysplasia do not go on to develop cancer, some patients may choose to have their Barrett’s Esophagus monitored closely with frequent endoscopy and biopsies, as frequent as every 3 months.  This high frequency of endoscopy is only needed in Barrett’s Esophagus with high grade dysplasia where other management approaches are not pursued.

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