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Barrett's esophagus

Definition


Disease: Barrett's esophagus Barrett's esophagus
Category: Digestive diseases
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Disease Definition:

Because of repeated exposure to stomach acid, the color and composition of the cells lining a person’s lower esophagus can change, causing Barrett’s esophagus. In most cases, long-term gastroesophageal reflux disease (GERD) is the cause of exposure to stomach acid. GERD is a chronic regurgitation of acid from the stomach into the lower esophagus.

Although once Barrett’s esophagus is diagnosed there’s a greater risk of developing esophageal cancer, however, this condition is quite uncommon, and only a small number of people with GERD develop it.
Someone with Barrett’s esophagus has less than 1% risk of esophageal cancer.

By making lifestyle changes, a person can reduce and even eliminate stomach acids flowing up into the lower end of their esophagus, which in turn reduces or eliminates their chance of developing Barrett’s esophagus.
 

Work Group:


Prepared by: Scientific Section

Symptoms, Causes

Symptoms:

Having GERD can lead to Barrett’s esophagus. Some of the common indicators of GERD are heartburn and acid reflux, which is the sensation of bad-tasting liquid that may enter the mouth from the throat. However, Barrett’s esophagus itself doesn’t have specific symptoms.

One suggestive sign of Barrett’s esophagus is when the color of the tissue lining the lower esophagus changes from its normal pink color to a salmon color. This cellular change, which is called metaplasia, is the result of repeated and long-term exposure to stomach acid.

A complication of GERD or Barrett’s esophagus, including the development of esophageal cancer may be suggested by these symptoms:

Weight loss and loss of appetite:
This could be unexpected.

Trouble swallowing:
Usually, having trouble swallowing (dysphagia) could be the result of narrowing of the esophagus (esophageal stricture).

Bleeding:
The person’s stools may be black, tarry or bloody, and they may vomit red blood, or blood that looks like coffee grounds.
 

Causes:

Even though Barrett’s esophagus usually develops in people who have GERD, however, the exact cause of Barrett’s esophagus is not known.

Normally, by closing tight, the ring of muscle at the junction of the esophagus and stomach (sphincter) keeps acid in the stomach.
A weakened sphincter that can be aggravated by a protrusion of the upper stomach through the diaphragm (hiatal hernia) usually causes GERD.

GERD can lead to more-serious complications when left untreated.
Intense chest pain could be caused by severe heartburn with inflamed esophageal tissue (esophagitis), which could resemble a heart attack.

Some of the other complications of GERD include Barrett’s esophagus, esophageal cancer and esophageal stricture, in which scarring causes narrowing of the esophagus, bleeding.
 

Complications

Complications:

A person’s risks of developing esophageal cancer are increased if they have Barrett’s esophagus. The earlier metaplasia is detected, the better.

Barrett's esophagus may develop precancerous changes (dysplasia) in grades ranging from none (no dysplasia), to mild but still significant changes (low-grade), to serious changes (high-grade), and finally to invasive cancer.

When high-grade dysplasia is detected, cancer often is already present. Cancer can spread to the other parts of the body, such as the nearby lymph nodes. The patient will be probably asked for more tests when high-grade dysplasia is present, such as a CT scan of the chest and abdomen and an endoscopic ultrasound to look for signs of cancer. This endoscopic ultrasound is similar to an endoscopy, but it allows the doctor to better examine the wall of the esophagus and surrounding lymph nodes using sound waves. During this procedure, biopsies of suspicious lymph nodes can be done.
 

Treatments:

Preventing the development of esophageal cancer is the main goal of treating Barrett’s esophagus. If dysplasia in Barrett’s esophagus hasn’t yet advanced to cancer, it isn’t too late to treat it.

Controlling GERD by making a number of lifestyle changes and taking self-care steps is what treatment for Barrett’s esophagus could start with. Losing weight, avoiding foods that aggravate heartburn, stopping smoking if the patient smokes, taking antacids or stronger acid-blocking medications, and elevating the head of their bed to prevent reflux during sleep are some of the self-care steps mentioned above.

Aggressive treatment is needed with people who have severe GERD and Barrett’s esophagus, including medications, some other nonsurgical medical procedures or even in some cases, surgery.


MEDICATIONS:
Some of the medications that are used in treating GERD and Barrett’s esophagus are:

Proton pump inhibitors (PPIs):
These medications block the production of acid and relieve irritated tissue. Some examples are lansoprazole , omeprazole , esomeprazole  and pantoprazole .

H-2-receptor blockers:
Although these drugs are less expensive than PPIs, but they are also weaker. Sometimes, these drugs are prescribed to treat GERD and Barrett’s esophagus. Cimetidine , ranitidine , famotidine  and nizatidine are some of the prescription H-2-receptor blockers that are also available over-the-counter in doses less than prescription strength.

Even though these medications are very effective for GERD, but they won’t reliably reverse the condition once Barrett’s metaplasia is present, and even if the patient’s GERD symptoms go away with treatment, the risk of cancer still remains.


SURGERY:
Anti-reflux surgery (laparoscopic Nissen fundoplication), which tightens the sphincter by wrapping a part of the stomach around the lower esophagus to prevent acid reflux, offers an alternative to long-term use of medication for GERD. During this procedure, small instruments are inserted through small incisions, which are less than an inch, leaving only tiny scars. Once Barrett’s metaplasia is present, surgery won’t reliably reverse the condition and the risk of cancer remains, even though surgery can be effective for GERD. After this surgery, the patient should stay in the hospital for one or two days.

The patient may be recommended undergoing a major surgical procedure in case they have esophageal cancer and barrett’s esophagus with high-grade dysplasia. In this surgical procedure, which is called an esophagectomy, the esophagus is removed completely and the stomach is pulled into the chest. Recovery could take up to two weeks in the hospital. This treatment, even though effective, is associated with significant health risks. Almost half of the people who undergo esophagectomy, experience at least one serious complication, some of which are heart attack, pneumonia and infections at the surgical site.

There are some experts who believe that esophagectomy should be used as a measure to protect against cancer, but other experts believe that it is sufficient to schedule screening endoscopies every three to six months and perform an esophagectomy only if cancer develops. Thus, the surgical treatment of people with high-grade dysplasia is controversial. Usually, surgery isn’t recommended for people with declining health, or those who are too weak to withstand this major procedure.

The reversal of Barrett’s esophagus is possible with the removal (ablation) of dysplasia, and it may even prevent esophageal cancer. In case the patient is not a good candidate for an esophagectomy, ablation may be appropriate when combined with PPIs.
Some of the ablation procedures include:

Electrocautery:
In this procedure an electric wire is inserted into the esophagus to burn away dysplasia.

Argon plasma coagulation:
In this procedure a jet of argon gas along with an electric current is released into the esophagus to burn away dysplasia.

Photodynamic therapy (PDT):
During this procedure the patient will be injected a drug called porfimer sodium , which makes the Barrett’s cells sensitive to light, and then a specialized light source will be inserted into the esophagus, causing a reaction with the porfimer that destroys Barrett’s cells.

Endoscopic mucosal resection:
The patient may be recommended following this procedure with photodynamic therapy. In this procedure, a saline solution is injected using an endoscope under the area of the esophagus that contains dysplasia. A blister will form under these abnormal cells, allowing the abnormal area to be cut away from the underlying tissue without damaging the rest of the esophagus.

Laser therapy:
In this procedure, a hot beam of light is inserted into the esophagus, in order to burn away Barrett’s cells.
 

Prognosis:

Not available

Expert's opinion

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