What is Barrett Esophagus (Barrett Esophagus)?
Barrett’s esophagus (BE) is a condition that changes the normal lining of the esophagus, the tube that carries food from your mouth to your stomach, into a different kind of tissue. However, health experts worldwide haven’t agreed on the exact criteria for diagnosing BE. Most cases of BE occur due to long-term acid reflux disease. However, some rare families have a genetic tendency to develop BE.
People with BE have a higher risk of developing changes in the esophageal lining that can lead to cancer, which can be severe. Monitoring programs have been created to guide treatment decisions based on the state of BE, whether it’s non-changeable, slightly changeable, significantly changeable, or has already turned into cancer.
These guidelines keep changing as new research comes along. The timing of different minimally invasive treatments and surgeries is another area that has seen recent changes. As technology progresses, researchers are interested in understanding which patients are most at risk and this could impact future guidelines on diagnosing and treating BE.
What Causes Barrett Esophagus (Barrett Esophagus)?
Most people who have Barrett’s Esophagus (BE) also have a history of chronic GERD. GERD, or gastroesophageal reflux disease, is when stomach and bile acids splash up from the stomach, through a ring of muscle called the lower esophageal sphincter, and into the lower part of the esophagus. The stomach lining is designed to handle the acidic environment needed for digestion. However, the esophagus is not. It’s lined with a different type of cell, and when it’s exposed to the acid, it becomes inflamed. If this exposure to stomach acid continues, the lining of the esophagus can start to change, eventually causing an intestinal-type state, which includes certain types of cells, known as goblet cells.
There are several risk factors for GERD. It could be due to conditions that weaken the lower esophageal sphincter, like a hiatal hernia or pregnancy. It could also be from conditions that put pressure on the stomach, such as obesity, pregnancy, and asthma. Finally, conditions which impair the movement of food from the stomach to the small intestine, such as diabetes, peptic ulcer disease, and connective tissue disorders, can also increase the risk.
It’s still unclear why some people with GERD develop BE and others don’t. However, research points to a few risk factors. Men are three times more likely than women to develop BE, and it is more prevalent in individuals of white ethnicity. The prevalence of BE also increases with age. Obesity also is a strong risk factor for both GERD and BE, specifically for those with more fat around their abdomen than just considering their body mass index (BMI).
Risk Factors and Frequency for Barrett Esophagus (Barrett Esophagus)
GERD, or heartburn, is a widespread condition affecting between 8 to 40% of the global population. Barrett’s Esophagus (BE), a condition where the tissue lining the esophagus changes, is seen in 1.3 to 1.6% of the general population and in 5 to 15% of patients with GERD symptoms who undertake an endoscopy. However, its prevalence in children is less, reaching up to 4.8%. The occurrence of GERD, BE, and esophageal adenocarcinoma (EAC), a type of cancer in the esophagus, has been rising over the last forty years. This increase might be partially due to more people getting endoscopies, but it highlights the urgent need for improved management and further research of these conditions.
Fortunately, over 95% of patients with BE do not develop cancer. The yearly risk of EAC in those with BE but without dysplasia (abnormal cells) is between 0.1 to 0.5%. If someone has low-grade dysplasia, the risk varies significantly from 1 to 43% per year, while those with high-grade dysplasia have a risk between 23 to 60% per year. Having more extensive dysplasia, or endoscopic abnormality, significantly increases the risk of developing cancer.
Signs and Symptoms of Barrett Esophagus (Barrett Esophagus)
Barrett’s esophagus, often abbreviate as BE, is a condition commonly associated with symptoms of GERD (Gastroesophageal Reflux Disease). The most recognized symptom is heartburn, a burning sensation in the chest, which often occurs after eating. Another typical symptom is acid regurgitation. Less common but still possible symptoms include dysphagia (difficulty swallowing) and a globus sensation. This sensation is when individuals feel like there’s a ‘lump’ or obstruction in their throat where there is none. Occasionally, patients may show no symptoms at all. Often, patients with Barrett’s esophagus have a long-term history of GERD symptoms, but there are usually no other specific physical examination findings.
- Burning sensation in the chest (heartburn), especially after eating
- Acid regurgitation
- Dysphagia (Difficulty swallowing)
- Globus sensation (Feeling like there’s a ‘lump’ in their throat)
- No symptoms at all, in rare cases
Testing for Barrett Esophagus (Barrett Esophagus)
In 2016, the American College of Gastroenterology (ACG) released an updated guide for diagnosing and managing a condition known as Barrett’s Esophagus (BE). The ACG now advises doctors to screen men with chronic acid reflux symptoms, lasting for five years or more, for BE if they have at least two more risk factors. These factors include being over 50 years old, a history of smoking, being of white ethnicity, central obesity, or having a confirmed family history of BE. Because it is very rare for women to develop esophageal adenocarcinoma (EAC), a type of cancer, they generally don’t need to be screened unless they have multiple risk factors.
Moreover, the ACG defined BE diagnosis through both visual identification of certain cells and a positive biopsy result. Normally, the cells under the microscope should resemble “salmon-pink” tissues and display specific structures called goblet cells. However, other professional groups, like the British Society of Gastroenterology and the GERD Society Study Committee in Japan, consider the presence of these goblet cells optional. To ensure accurate diagnosis, the ACG recommends taking at least eight biopsy samples.
If BE is identified, a pathologist also needs to check if there are any signs of pre-cancerous cells or cancer itself. These signs could be detected under a microscope. Of note, the amount of pre-cancerous cells can hint at the risk of developing cancer. Therefore, it is essential for doctors to examine thoroughly how much these cells are present, even though they might not be seen visually during the endoscopy.
Pre-cancerous or cancerous cells associated with BE may resemble those found in some colon tumours, but other types also exist. However, there’s only a classification standard for one type called intestinal-type dysplasia. Low-grade intestinal dysplasia may show mildly abnormal cell structures while high-grade cells will show a more severe abnormality like crowded cells and varying cell shapes and sizes.
In some cases where the cell changes are uncertain, pathologists might label the case as “Indefinite for Dysplasia”. The line between high-grade dysplasia and a specific type of cancer called intramucosal carcinoma is sometimes unclear. There are specific criteria recommended for diagnosing intramucosal carcinoma which include observing invasive cancer cells, irregular gland shape, and oddly shaped cell formations.
Treatment Options for Barrett Esophagus (Barrett Esophagus)
In the past, strategies for monitoring diseases have often been random and not backed up by strong scientific studies. In fact, a study from 2014 found no link between disease monitoring and a decrease in deaths from esophageal adenocarcinoma, a type of cancer that starts in the cells that make mucus in the esophagus.
However, based on their review of various studies, the American College of Gastroenterology (ACG) made some updates to their guidelines on managing Barrett’s Esophagus (BE), a condition where cells in the esophagus change or get damaged due to acid reflux. One of the recommendations is the use of high-definition white-light endoscopy. This advanced technology, better than normal endoscopy, is now advised for regular check-ups.
For BE without signs of dysplasia (abnormal cells), the ACG suggests a check-up every 3 to 5 years after diagnosis. In this case, patients are advised to take proton pump inhibitor medication daily, regardless if they experience acid reflux symptoms or not, as this type of medicine can help prevent BE from developing into cancer.
When BE is associated with abnormal cells, the ACG highlights the need to have a second pathologist confirm the diagnosis. These patients can now opt for endoscopic ablative therapy (using heat to remove abnormal tissue) or undergo monitoring every 6 to 12 months. For patients with a high volume of abnormal cells along with endoscopic mucosal abnormalities, it’s advised to remove the abnormal area and then destroy the remaining changed esophagus tissue. If flat and unchanged, radiofrequency ablation (using heat to treat the anomaly) or cryotherapy (using cold for treatment) is considered enough for treatment.
Even after treatment, patients need continued monitoring since it often takes multiple sessions to completely eliminate abnormal tissue. Surgery, such as esophagectomy (removal of the esophagus), is not the first choice for treating a high volume of abnormal cells or cancer on the inner layer of the esophagus since it involves substantial risks. However, it might be considered if the inner layer of cancer has worrisome features, or if cancer has reached the submucosa (the layer underneath the top). Patients with serious health conditions that could limit their lifespan may not benefit from diagnosis and treatment procedures. In these cases, the risks may outweigh the benefits.
What else can Barrett Esophagus (Barrett Esophagus) be?
- Sudden inflammation of the stomach lining (Acute gastritis)
- Narrowing or web-like structure in the lower part of the stomach (Antral web)
- Gallstones (Cholelithiasis)
- Long-term inflammation of the stomach lining (Chronic gastritis)
- Hardening/blockage of the heart’s blood vessels (Coronary artery atherosclerosis)
- Cancer of the food pipe (Esophageal cancer)
- Disorders affecting the movement of the food pipe (Esophageal mobility disorders)
- Sudden, severe pain in the food pipe (Esophageal spasm)
- Inflammation of the food pipe (Esophagitis)
- Gallstones
- Infections caused by a type of bacteria known as Helicobacter pylori
What to expect with Barrett Esophagus (Barrett Esophagus)
It’s now widely accepted that if Barrett esophagus is not treated, it can eventually develop into a kind of cancer known as adenocarcinoma. However, this progression usually happens very slowly, and most patients won’t develop this cancer. Despite this, it’s worth noting that the number of adenocarcinoma cases has been rising steadily over the past 30 years.
Preventing Barrett Esophagus (Barrett Esophagus)
While there isn’t a clear-cut answer on the link between diet and the development of Barrett’s esophagus, doctors generally recommend that patients cut down on their meat consumption. Patients are also asked to avoid foods and beverages that are oily, alcoholic, caffeinated, chocolaty, or acidic – this includes juices, vinegar, and fizzy drinks.
The American College of Gastroenterology suggests that people should consider having an upper endoscopy – a test to check the state of your esophagus – once they turn 50. This is to help detect or monitor Barrett’s esophagus condition.
