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Barrett's Esophagus

It afflicts only one percent of adults in the United States. Barrett’s esophagus is a complication of chronic gastroesophageal reflux disease (GERD), also known as acid reflux or severe heartburn. Yet, for those who have the condition, complications are serious.

“Patients with Barrett’s esophagus can go on to develop esophageal cancer,” says Steven Edmundowicz, MD, Washington University gastroenterologist and director of interventional endoscopy at Barnes-Jewish Hospital and Barnes-Jewish West County Hospital. “Cancer of the esophagus usually is deadly. Less than 15 percent of patients with esophageal adenocarcinoma survive for five years, and in those with advanced Barrett’s esophagus, the risk that the condition will advance to become cancer is about 6 percent per year.”

Other GI Breakthroughs

Transoral Gastroplasty

In 2008, doctors at Washington University School of Medicine performed the first non-surgical procedure in the United States that restricts the size of the stomach to treat obesity at Barnes-Jewish Hospital.

During the procedure, known as transoral gastroplasty or TOGA, the physician introduces a set of flexible stapling devices through the mouth into the stomach and then uses the staplers to create a restrictive pouch. The pouch catches food as it enters the stomach, giving patients the feeling of fullness after eating less. While not as quick of a weight-loss procedure as gastric bypass surgery, the key benefits from an endoscopic procedure as compared to laparoscopic or open surgery are quicker recovery period, shortened hospital stay, and an incision-free procedure.

High-Resolution Manometry

For patients with trouble swallowing, an enhanced diagnostic tool developed by Washington University gastroenterologists at Barnes-Jewish Hospital can help physicians identify the problem. Manometry is the measurement of pressure inside the esophagus during its normal swallowing action. Localizing the source of the swallowing problem to specific areas of the esophagus is the key to better understanding of the patient’s disorder and to directing effective treatment.

The older or traditional manometry, still widely used across the country, records from sensors spaced far apart along a catheter inserted through the nose into the esophagus and down into the stomach. The new tool, called high-resolution manometry, has 36 circumferential sensors placed only one centimeter apart along the catheter’s entire length. This offers a shorter and more comfortable experience for the patient, and more detailed results for diagnosis.

“This new computerized technology fills deficiencies in the previous diagnostic tools. By assigning colors to different pressure levels, it provides a topographic map of how the esophagus works,” says Chandra PrakashGyawali, MD, director of the Gastroenterology Physiology and Motility Laboratory.

Research to assess treatment outcomes and to further improve advanced manometry and impedance techniques are ongoing at the Center.

A breakthrough procedure used by Edmundowicz’s team that employs heat generated by radio waves to treat Barrett’s esophagus can eliminate signs of the potentially cancer-causing disorder and reduce the risk that the disease will progress.

 Approximately 10 percent to 15 percent of individuals with chronic symptoms of GERD develop Barrett’s esophagus, more common in white males than any other group. And it is increasing in frequency. In Barrett’s esophagus, the lower esophageal sphincter (LES)—a valve that is located at the junction of the stomach and the esophagus—is weak and cannot prevent acid and other contents of the stomach from coming back into the esophagus.

Because of excessive damage caused by the acid, the normal cells that line the esophagus, called squamous cells, turn into cells similar to the lining of the intestine, called columnar cells. This process is called intestinal metaplasia, and the specialized columnar cells are not usually found in the esophagus. As the condition progresses, these cells become increasingly disordered and may become precancerous. Though the risk
of esophageal cancer is low, it increases in patients with chronic reflux.

Treating the Disease

Symptoms of the condition include everything from chest pains to vomiting, difficulty swallowing, and hemorrhaging. Yet, a person can also be asymptomatic and have no signs of problems, or the symptoms of Barrett’s esophagus may resemble other medical conditions.Currently there is no cure for Barrett’s esophagus. Once the cells in the esophageal lining are replaced by columnar cells, they will not revert back to normal. Therefore, treatment is traditionally aimed at preventing further damage by stopping acid reflux from the stomach. The main challenge in this condition is to watch for early signs of cancer by taking biopsies at regular intervals during endoscopy. This surveillance practice is similar, in principle, to the surveillance in women for cervical cancer, wherein PAP smears are taken at regular intervals.

In mild cases, over-the-counter medications are used, ranging from antacids to low doses of drugs called H-2 receptor antagonists or H2 blockers, such as Pepcid or Zantac. The more persistent the symptoms, the stronger the medication, including proton pump inhibitors (PPIs).

In more severe cases, the traditional operation, called fundoplication, involves wrapping the upper stomach around the lower end of the esophagus. The purpose of the wrap is to tighten the lower esophageal sphincter in order to prevent the reflux. However, there is no evidence that anti-reflux surgery or acid suppression therapy with drugs decreases the risk of esophageal cancer among patients with Barrett’s. And even with minimally invasive laparoscopic technologies, the risks of surgery remain.

The newest procedure, called radiofrequency ablation, takes out those risks and gives patients a promising alternative to surgery.

The outpatient procedure takes about 30 minutes and uses a small scope inserted through the mouth to diagnose the disease and then destroy the abnormal tissue.

A mild, painless radiofrequency energy similar to microwave heat is transmitted to the affected area through an instrument at the tip of the scope that destroys carefully selected cells in a very small section. The technique leaves the deeper layers of the esophagus undamaged, allowing them to heal naturally. There is no need for large incisions, and physicians can track what they are doing using video screens.

Recent Studies

Even more promising are results from a recent Washington University clinical study of patients who had received ablation treatment. Dysphasia, which is abnormal cell growth, disappeared in just over 90 percent of patients with low-grade disease and in more than 80 percent of those affected with the more severe high-grade disease. This is compared to about 20 percent of the patients who used traditional medication treatment and did not receive ablation therapy. In 78 percent of treated patients, not only did dysplasia disappear, but all the abnormal intestinal-type cells were eliminated as well.

Patients go home just hours after the procedure. “The one side effect that most ablation patients experience is soreness in the chest following therapy,” says Edmundowicz. Minor swallowing difficulty can also occur for five to seven days. “This was easily managed with medications, and patients are less sore than if they had surgery, which has been the primary treatment option.”

Radiofrequency ablation is still not considered a cure for Barrett’s esophagus or its progression to esophageal cancer, as more research is needed. However, Edmundowicz is enthusiastic about the new technique.

“From these short-term results, it appears we may have another useful tool in our treatment arsenal,” says Edmundowicz.  

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