Gastroenterology

Barrett's esophagus

Marina Virko
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Johannes Grossmann

Barrett's esophagus is an abnormal condition in which the squamous epithelium of the upper digestive tract is replaced by the columnar one. It is associated with chronic inflammation and is considered a precursor to cancer. The diagnosis puts to your treating physician a challenging question: is immediate intervention necessary, or will dynamic monitoring be sufficient?

Overview

The normal esophageal mucosa consists of squamous epithelium, whose cells are scale-like (it is also called squamous, from the Latin word squāma, meaning “a scale”). English thoracic surgeon Norman Barrett, in a paper published in 1950, was the first to describe cases in which he had observed cylindrical epithelium characteristic of the intestine instead of it. At that time the doctor concluded that he was dealing with a part of the stomach, displaced due to congenital shortening. It was only much later that he agreed with colleagues who believed that it was metaplasia rather than organ deformity. Nevertheless, the pathology was eventually named after him.

Causes of Barrett's syndrome

The underlying factor in the development of the disease is the so-called gastroesophageal reflux, that is, the rise of gastric contents into the esophagus. This aggressive mixture, consisting of acid, stomach enzymes and bile, causes severe irritation of the mucosa and destruction of its cells. To repair the damage, the body has to produce new epithelium. Normally, this should be the same squamous epithelium typical of this organ. However, sometimes the newly formed cells are more similar to those of the intestinal tissue. They are called columnar because of their columnlike or cylindrical shape. Areas of such intestinal metaplasia (that is, alien mucosa) can range in size from a few millimeters to several centimeters.

The risk of developing Barrett's syndrome with gastro-esophageal reflux is about 10%, and the average patient age is 57.5 years.

According to statistics, in men this abnormal condition occurs on average three times more often than in women.

Why is intestinal metaplasia dangerous?

Columnar cells are more resistant to external influences, but they have one negative feature: in an unnatural location, apoptosis (the process of programmed death) may be disturbed in them over time, leading to cancer. Statistics indicate that patients with Barrett's esophagus are 30-125 times more likely to develop adenocarcinoma than those in whom this condition is absent.

Disease symptoms

Since Barrett's esophagus is directly related to gastroesophageal reflux disease (GERD), commonly referred to as heartburn, the major complaints in both conditions are similar and may include:

a burning sensation behind the sternum;

  • difficulty swallowing food;
  • a feeling of fullness in the stomach;
  • frequent belching;
  • pain and a feeling of pressure in the chest.

Diagnostic procedures

Barrett's esophagus is detected by esophagoscopy, a visual examination using special optical equipment, which the doctor performs as part of an endoscopic examination of the upper digestive tract (gastroscopy).

Although an experienced gastroenterologist is able to recognize the signs of the disease “with the naked eye”, a biopsy followed by histological analysis of the obtained specimens is required for a definitive diagnosis.

The heterogeneity of metaplasia often makes it difficult to determine the sampling sites. To improve diagnostic accuracy, special techniques such as narrow band imaging (NBI), image-enhanced endoscopy and chromoscopy (staining of suspicious areas with special dyes) are recommended. In addition, to eliminate the possibility of error, physicians must follow a specific protocol outlined by current clinical guidelines. For example, it recommends taking at least 1 minute to examine each centimeter of the suspicious area, and sampling specimens not only from all visible abnormalities, but also from randomly selected 4 points on the circumference for every 2 cm of Barrett's esophagus.

Of major importance are pathology findings regarding the character of the alien columnar epithelium. There are three types:

  • cardial;
  • fundal;
  • specialized columnar epithelium of the intestinal type.

Only the latter is characterized by the presence of the so-called goblet cells, typical of the small intestine.

They are believed to be the evidence of intestinal metaplasia, i.e. the histologic criterion for the diagnosis of Barrett's esophagus.

Stages of Barrett's esophagus progression

An upper endoscopy can not only detect the presence of the disease, but also determine its extend and stage, which determine further treatment strategy.

The three disease stages include:

  1. metaplasia without dysplasia: no visible precancerous changes are detected;
  2. low-grade dysplasia: there are early precancerous changes;
  3. high-grade dysplasia: there are evident precancerous changes, which are considered as the stage immediately preceding adenocarcinoma.

Depending on the size of the area of altered mucosa, a distinction is made between “long” (or “classic”) and “short” variants of Barrett's esophagus. In the former case, the extent of metaplasia is 3 cm or more, in the latter it is less than 3 cm.

Accurate assessment of metaplastic changes in Barrett's esophagus is not an easy task. Patients are encouraged to make sure that their samples are examined at specialized laboratories or seek a pathology second opinion.

When is the right time to start Barrett's esophagus treatment?

In the first stage, regular checkups by endoscopy are sufficient. Their frequency depends on the extent of the lesion at the time when it was first detected. If the esophageal mucosa has undergone extensive changes (more than 3 cm in length), endoscopy should be performed every 2-4 years, and with changes of small extent (short Barrett's esophagus) it should be done every 4 years.

If even the slightest precancerous changes (dysplasia) are detected, the current guidelines recommend the diagnosis to be verified at a specialized facility.

If confirmed, management options include radiofrequency ablation to prevent progression or a repeat gastroscopy within 6 months followed by annual exams.

The presence of high-grade dysplasia is always a warning signal, as in 30-50% of these patients a cancerous tumor may already be present in another metaplastic area. In the past, it was an indication for radical cancer surgery. However, specialized centers now offer sophisticated techniques of endoscopic mucosal resection as an alternative.

Antireflux therapy is an essential part of Barrett's esophagus treatment strategy

In addition to dynamic monitoring, the main task in the early disease stages is to prevent gastroesophageal reflux and the resulting lesions. Currently, proton pump inhibitor drugs are used as first-line therapy. H2-receptor antagonists or antacids are recognized as less effective and can be used as a supplement.

In some cases, if conservative therapy fails, antireflux surgery, that is, surgery to remove the cause of GERD, may be considered. It is called fundoplication and its aim is to restore the normal length of the abdominal esophagus, to narrow it (chiatoplasty) and form a valve function.

Surgical treatment of Barrett's esophagus

Until relatively recently, esophageal surgery has been the standard procedure for high-grade dysplasia and early cancer. Even at centers of excellence it is involves risks and is associated with reduced quality of life. But nowadays, advances in healthcare have brought to the fore much safer minimally invasive procedures.

Endoscopic treatment options

Current minimally invasive treatments for Barrett's metaplasia include ablation and resection procedures.

Ablation (i.e. destruction) of abnormal tissue is performed using argon plasma coagulation or high frequency electric current (radiofrequency ablation). 

For endoscopic resection, the techniques of endoscopic mucosal resection and endoscopic submucosal dissection are used. In the first case, the working tool is a special loop, in the second case uses knives.

With dissection it is possible to remove larger mucosal areas in one go, which makes it easier to assess whether the lesion was removed completely, but it is associated with higher complication (bleeding and perforation) rates.

In most cases, a combination of therapeutic procedures is necessary to eliminate the metaplastic foci completely. Supplemented with drug therapy (substances that block gastric acid), they lead to the formation of normal mucosa, the squamous esophageal epithelium. To assess therapy results another tissue sampling is done. The treatment is to be followed by control endoscopies which the patients are encouraged to have at regular intervals.

Are there ways to prevent the disease?

You can avoid Barrett's esophagus if you avert GERD or treat it timely. To prevent reflux, it is recommended to stay away from foods and situations that can lead to increased stomach content volume and acid production. For example, large portions of high-fat foods slow down gastric emptying and put higher pressure on the lower esophageal sphincter. Hasty eating leads to excessive swallowing of air (aerophagia) and increased intra-abdominal pressure, while the consumption of cocoa, alcohol or too much sweets, especially chocolate, raises acidity.

Prognosis in Barrett's syndrome

The mere presence of alien epithelium in the esophagus does not necessarily lead to cancer. In general, the course of events is influenced by several factors: disease duration, stage of the cellular transformation, effectiveness of therapeutic procedures and management. In particular, with a high degree of dysplasia, the risk of adenocarcinoma is much higher than in cases of only initial changes.

In experienced hands, timely treatment by complete removal of metaplasia (including precancerous stages) has about a 90 percent chance of success.

However, studies show that even after complete eliminationi, Barrett's mucosa can recur after more than 5 years. This suggests that patients should be encouraged to continue endoscopic checkups at regular intervals.

If Barrett's esophagus develops into esophageal carcinoma (a dangerous cancer), the prognosis is significantly worse. Less than 25 percent of patients are still alive 5 years following the diagnosis. However, this is an average: actual life expectancy depends on various factors, especially detection and treatment timing.

Second opinion

The suspicion of Barrett's esophagus or an already confirmed diagnosis poses a number of difficult questions and challenges for the attending physician, from accurately assessing the nature and extent of mucosal changes to ensuring the best possible control and choosing the time and method of treatment.

The cost of error is very high: without timely therapy, a dangerous cancer may develop, whereas unnecessary surgery involves unjustified complication risks. The borderline between situations where observation alone is sufficient, and where there are indications for immediate action, is often too subtle, so only a very competent professional is capable of making the right decision.

Therefore, all current clinical guidelines support the need for a second opinion in cases of changes to the esophageal mucosa. They also encourage to refer to the most reliable sources, that is, doctors and healthcare facilities with special focus on this disease.

The MedconsOnline consultant portfolio includes experts with extensive experience in the diagnosis and treatment of Barrett’s esophagus. To get a qualified assessment of your issue and advice on the best treatment strategy, order your consultation in our gastroenterology section. 

References

  1. Peter M. Stawinski, Karolina N. Dziadkowiec, Lily A. Kuo, Juan Echavarria, Shreyas Saligram. Barrett’s Esophagus: An Updated Review. Diagnostics (Basel). 2023 Jan; 13(2): 321. Published online 2023 Jan 16. doi: 10.3390/diagnostics13020321
  2. Prateek Sharma. Barrett Esophagus. A Review. JAMA. 2022;328(7):663-671. doi:10.1001/jama.2022.13298
  3. Clermont M, Falk GW. Clinical Guidelines Update on the Diagnosis and Management of Barrett's Esophagus. Dig Dis Sci. 2018 Aug;63(8):2122-2128. doi: 10.1007/s10620-018-5070-z. PMID: 29671159.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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