Barrett’s esophagus is a condition in which the esophagus (the muscular tube that carries food and saliva from the mouth to the stomach) changes so that some of its lining is replaced by a type of tissue similar to that normally found in the intestine. This process is called intestinal metaplasia.

While Barrett’s esophagus may cause no symptoms itself, a small number of people with this condition develop a relatively rare, but often deadly, type of cancer of the esophagus called esophageal adenocarcinoma. Barrett’s esophagus is estimated to affect about 700,000 adults in the United States. It is associated with the very common condition gastroesophageal reflux disease (GERD).

Normal Function of the Esophagus

The esophagus seems to have only one important function in the body – to carry food, liquids and saliva from the mouth to the stomach. The stomach then acts as a container to start digestion and pump food and liquids into the intestines in a controlled process. Food can then be properly digested over time, and nutrients can be absorbed by the intestines.

Barret1The esophagus transports food to the stomach by coordinated contractions of its muscular lining. This process is automatic and people are usually not aware of it. Many people have felt their esophagus when they swallow something too large, try to eat too quickly, or drink very hot or very cold liquids. They then feel the movement of the food or drink down the esophagus into the stomach, which may be an uncomfortable sensation.

The muscular layers of the esophagus are normally pinched together at both the upper and lower ends by muscles called sphincters. When a person swallows, the sphincters relax automatically to allow food or drink to pass from the mouth and into the stomach. The muscles then close rapidly to prevent the swallowed food or drink from leaking out of the stomach back into the esophagus or into the mouth. These muscles make it possible to swallow while lying down or even upside-down. When people belch to release swallowed air or gas from carbonated beverages, the sphincters relax and small amounts of food or drink may come back up briefly; this condition is called reflux. The esophagus quickly squeezes the material back into the stomach, and this is considered normal.

While these functions of the esophagus are obviously an important part of everyday life, people who must have their esophagus removed, for example because of cancer, can live a relatively healthy life without it.

What is GERD?



[Read a more comprehensive article about GERD.]

Having liquids or gas occasionally reflux is considered normal. When it happens frequently, particularly when not trying to belch, and when it causes other symptoms, then it is considered a medical problem or disease. However, it is not necessarily a serious one or one that requires seeing a physician.

The stomach produces acid and enzymes to digest food, and when this mixture refluxes into the esophagus more frequently than normal or for a longer period of time than normal, it may produce symptoms. These symptoms, often called acid reflux, are usually described by people as heartburn, indigestion, or "gas."  The symptoms typically consist of a burning sensation below and behind the lower part of the breastbone or sternum.

Almost everyone has experienced these symptoms at least once, typically as a result of overeating. Other things that provoke GERD symptoms include being overweight, eating certain types of foods, or being pregnant. In most people, GERD symptoms may last only a short time and require no treatment at all. More persistent symptoms are often quickly relieved by over-the-counter acid-reducing agents such as antacids. 

Other drugs used to relieve GERD symptoms are antisecretory drugs such as histamine2 (H2) blockers or proton pump inhibitors. Common H2 blockers are

  • cimetidine (Tagamet® HB), famotidine (Pepcid® AC)
  • nizatidine (Axid® AR)
  • ranitidine (Zantac® 75) 

Common proton pump inhibitors are

  • esomeprazole (Nexium®)
  • lansoprazole (Prevacid®)
  • omeprazole (Prilosec®)
  • pantoprazole (Protonix®)
  • rabeprazole (Aciphex®) 

People who have symptoms frequently should consult a physician. Other diseases can have similar symptoms, and prescription medications in combination with other measures might be needed to reduce reflux. GERD that is untreated over a long period can lead to complications, such as an ulcer in the esophagus that could cause bleeding. Another common complication is scar tissue that blocks the movement of swallowed food and drink through the esophagus; this condition is called stricture

Esophageal reflux may also cause certain less common symptoms, such as hoarseness or chronic cough, and sometimes provokes other conditions such as asthma. While most patients find that lifestyle modifications and acid-blocking drugs relieve their symptoms, doctors occasionally recommend surgery. Overall, GERD is one of the most common medical conditions. Some 20 percent of the population can be affected over a lifetime.

Learn more about GERD.

What causes Barrett’s Esophagus?



The exact causes of Barrett’s esophagus are not known, but it is thought to be caused in part by the same factors that cause GERD. Although people who do not have heartburn can have Barrett’s esophagus, it is found about three to five times more often in people with this condition. Barrett's is a benign conditon, however there is a risk that over time, it can evolve into what is called low-grade dysplasia, where the cells of the esophageal lining begin to go through a transformation. From there it can progress to high-grade dysplasia, followed by adenocarcinoma. By performing periodic regular surveillance endoscopy, we can detect if and when this change might begin, thereby preventing an esophageal cancer from occurring.

Barrett’s esophagus is uncommon in children. The average age at diagnosis is 60, but it is usually difficult to determine when the problem started. It is about twice as common in men as in women and much more common in white men than in men of other races.

Barrett’s Esophagus and Cancer of the Esophagus



Barrett’s esophagus does not cause symptoms itself and is important only because it seems to precede the development of a particular kind of cancer – esophageal adenocarcinoma. The risk of developing adenocarcinoma is 30 times higher in people who have Barrett’s esophagus than in people who do not. This type of cancer is increasing rapidly in white men. The increase is possibly related to the rise in obesity and GERD.

For people who have Barrett’s esophagus, the risk of getting cancer of the esophagus is small: less than 1 percent per year, but still higher than the average population. Esophageal adenocarcinoma is often not curable, partly because the disease is frequently discovered at a late stage and because treatments are not effective.

Diagnosis and Screening



Diagnosing Barrett’s esophagus is not possible based on symptoms alone. At the present time, it cannot be diagnosed on the basis of symptoms, physical exam or blood tests. The only useful test is upper gastrointestinal endoscopy and biopsy. In this procedure, a flexible tube called an endoscope, which has a light and miniature camera, is passed into the esophagus. If the esophageal mucosal lining appears to have characteristics of Barrett's esophagus, then biopsies are taken. A biopsy is the removal of a small piece of tissue using a pincher-like device passed through the endoscope. A pathologist examines the tissue under a microscope to confirm the diagnosis.

Many physicians recommend that adult patients who are over the age of 40 and have had GERD symptoms for a number of years have endoscopy to see whether they have Barrett’s esophagus. Screening for this condition in people who have no symptoms is not recommended.

Treatment



Barrett’s esophagus has no cure, short of surgical removal of the esophagus, which is a serious operation. Surgery is recommended only for people who have a high risk of developing cancer or who already have it. Most physicians recommend treating GERD with acid-blocking drugs, since this is sometimes associated with improvement in the extent of the Barrett's tissue and/or may be helpful in preventing the Barrett's from progressing further. However, this approach has not been proven to reduce the risk of cancer. Treating reflux with a surgical procedure for GERD also does not seem to cure Barrett’s esophagus.

Surveillance for Dysplasia and Cancer



Periodic endoscopic examinations to look for early warning signs of cancer are generally recommended for people who have Barrett’s esophagus. This approach is called surveillance. When people who have Barrett’s esophagus develop cancer, the process seems to go through an intermediate stage in which cancer cells appear in the Barrett’s tissue. This condition is called dysplasia and can be seen only in biopsies with a microscope. The process is patchy and cannot be seen directly through the endoscope, so multiple biopsies must be taken. Even then, it can be missed.

The process of change from Barrett’s to cancer seems to happen only in a few patients, less than 1 percent per year, and over a relatively long period of time. Most physicians recommend that patients with Barrett’s esophagus undergo periodic surveillance endoscopy to have biopsies. The recommended interval between endoscopies varies depending on specific circumstances, and the ideal interval has not been determined.

Treatment for Dysplasia or Esophageal Adenocarcinoma



If a person with Barrett’s esophagus is found during their survillence endosocpy to have developed dysplasia, then it is advised to have treatment for this. Presently, there are treatments that can be provided by an endoscopic approach, or if necessary through surgery. For low grade or high grade dyspasia, an endoscopic  procedure to ablate the Barretts tissue lining is performed using Argon Plasma Coagulation therapy (HALO). This is a method where through an endoscope, an electrode is apllied to the lining of the Barrett's while sedated, and heat energy is applied that specificallly targets only the layer of Barrett's tissue without harming the healthy structures underneath it. When this area heals, normal healthy tissues replaces it, thus eliminating the Barrett's (intestinal metaplasia) altogether. It usually requires several sessions every couple of months until completed. The HALO radiofrerqeucy ablation procedure is considered very safe with a very low risk of scarring, stricturing or perforation. There may be minor side effects for 24-48 hours afterwards, such as chest discomfort, or difficulty swallowing, and the physician will provide medicine to manage these symptoms. 

If there are nodules in the lining of the esophagus detected at the time of endoscopy, another endoscopic approach might be considered. If adenoacarcinoma is determined or suspicious on biopsy, then a procedure call Endoscopic Ultrasound (EUS) can be prformed. This is done with a special endoscope that has an ultrasound transducer on its tip. By placing this endoscopic within the esophagus, the endoscopist can visualized the deepr layers of the esophagus as well as the surrounding tissues to see if there are any suspicious changes. If necessary, biopsies can be directly to these area at the time of the procedure. 

For nodular lesions in the lining of Barrett's esophagus, which are often the beginning of adenocarcinoma, another endoscopic procedure called Endoscopic Mucosal Resection (EMR) can be considered. This device is used at the time of endoscopy to remove these nodular areas by slicing through it in a somewhat deeper fashion, in order to remove all of the tissue, not just the superficial lining. Physicians with advanced Endoscopic training are consulted in order to perform this procedure when necessary.

Lastly, if surgery is required, then a thoracic surgeon with experience in esophageal surgery would be consulted to perform an esophageal resection.

Points to Remember

  • In Barrett’s esophagus, the cells lining the esophagus change and become similar to the cells lining the intestine.
  • Barrett’s esophagus is associated with gastroesophageal reflux disease or GERD.
  • A small number of people with Barrett’s esophagus may develop esophageal cancer. Barrett’s esophagus is diagnosed by upper gastrointestinal endoscopy and biopsy.
  • People who have Barrett’s esophagus should have periodic esophageal examinations.
  • Taking acid-blocking drugs for GERD may result in improvements in Barrett’s esophagus.
  • In cases where low-grade or high-grade dysplasia is detected, or in some cases of intestinal metaplasia alone, Endoscopy with Radiofrequency Ablation (HALO) might be performed to eliminate the diseased tissue, leaving healthy tissue undamaged.
  • Removal of the esophagus is recommended only for people who have a high risk of developing cancer that cannot be treated endoscopically, or who already have it.