Barrett's Esophagus

Barrett's esophagus is a condition in which the esophagus 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 does not cause 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 or GERD.

GERD and 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 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 is important only because it precedes the development of esophageal adenocarcinoma. The risk of developing adenocarcinoma is 30 to 125 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. This increase may be 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 (0.4 percent to 0.5 percent) per year. 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

Barrett's esophagus can only be diagnosed by an upper GI endoscopy to obtain biopsies of the esophagus. At present, it cannot be diagnosed on the basis of symptoms, physical exam, or blood tests. In an upper GI endoscopy, a flexible tube called an endoscope, which has a light and miniature camera, is passed into the esophagus. If the tissue appears suspicious, then biopsies must be done. 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 an 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. 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. 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.

Several different experimental approaches are under study. One attempts to see whether destroying the Barrett's tissue by heat or other means through an endoscope can eliminate the condition. This approach, however, has potential risks and unknown effectiveness.

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, the cancer cells can be missed.

The process of change from Barrett's to cancer seems to happen in only 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 to have dysplasia or cancer, the doctor will usually recommend surgery if the person is strong enough and has a good chance of being cured. The type of surgery may vary, but it usually involves removing most of the esophagus and pulling the stomach up into the chest to attach it to what remains of the esophagus. Many patients with Barrett's esophagus are elderly and have many other medical problems that make surgery unwise; in these patients, other approaches to treating dysplasia are being investigated.

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.
  • Removal of the esophagus is recommended only for people who have a high risk of developing cancer or who already have it.

Source: National Digestive Diseases Information Clearinghouse (NDDIC)