Gastroenterology

Barrett's esophagus (Barrett's syndrome)

Marina Virko
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Christian Trautwein

Barrett's esophagus is a precancerous lesion that develops due to a chronic inflammatory process which results in the degenerayion of the squamous epithelium of the esophagus into columnar epithelium. There is a high probability that the disease will develop into an adenocarcinoma of the esophagus. Predisposing factors are age over 50, overweight, smoking and alcohol abuse, oesophageal hernia.

General information about Barrett's syndrome

Barrett's syndrome is a severe disease that develops as a result of constant irritation of the oesophageal mucosa by gastric juice due to gastroesophageal reflux disease. The condition was first described in 1950 by the English surgeon Norman Barrett. At that time, the condition was considered normal in a shortened oesophagus and stomach displacement with the formation of metaplastic epithelium. It was not until 7 years later that Barrett proved that epithelium containing goblet cells indicated precancerous disease.

According to statistics, the syndrome develops in 80% patients with GERD (gastroesophageal reflux disease). At the same time, there is a direct relation to age, that is, the duration of reflux history.

Barrett's oesophagus is 5 times more often detected in men. The probability of malignization in them is 9 times higher.

Causes of Barrett's syndrome

The main cause of mucosal changes is the presence of gastroesophageal reflux. As a result of stomach contents being thrown into the esophagus, it gets constantly irritated. Due to the permanent injury the squamous epithelium of the oesophagus is replaced with columnar, which is more resistant to negative impact. As the condition progresses, cells with a disturbed process of apoptosis (programmed death) are formed. This becomes the cause of dysplasia, and subsequently leads to oesophageal cancer.

Factors that increase the risk of developing the disease are known and include:

  • a long history of smoking;
  • severe excess weight;
  • hiatal hernia;
  • metabolic syndrome.

Symptoms of Barrett's syndrome

The manifestations of the disease are very similar to the signs of GERD. This is explained by the fact that the mechanism of their development is the same. The main complaints are:

  • heartburn after eating or on exertion;
  • belching;
  • dry cough;
  • difficulty swallowing food;
  • feeling of heart palpitations;
  • signs of anaemia.

With significant metaplasia, patients with Barrett's oesophagus may complain of a feeling of lump in the chest.

Doctors often prescribe drugs to reduce the concentration of gastric juice, without paying attention to the diagnosis. This leads to progression of Barrett's syndrome and an increased risk of degeneration into cancer.

Diagnostic procedures

The only method of detecting Barrett's syndrome is a gastroscopy. During the endoscopic examination, a biopsy is performed with subsequent histological analysis of the tissue samples.

In the case of poor visualisation, chromoendoscopy is used. It involves staining the suspicious areas of the oesophageal mucosa with dyes, which makes it possible to identify areas of change.

To diagnose Barrett's oesophagus, doctors can also prescribe MRI, CT, X-ray with contrast.

During the examination, the doctor not only detects the presence of the disease, but also determines its stage.

Stages of Barrett's esophagus progression

In the course of its development, the disease passes through three stages.

Metaplasia (benign changes) without dysplasia (malignization): no visible precancerous changes of cells in the esophageal mucosa.

Low-grade dysplasia: cells show early precancerous changes that may lead to cancer.

High-grade dysplasia: esophageal cells show a high degree of precancerous changes that are considered the last stage before esophageal adenocarcinoma.

Treatment of Barrett's syndrome

As soon as Barrett's syndrome is detected, it is important to start treatment immediately. Both drug therapy and surgical treatment can be used.

Drug therapy

The choice of medication depends on what symptoms the patient has and what type of degeneration was identified. Drugs to reduce the concentration of hydrochloric acid are mandatory. As a rule, these are proton pump blockers.

Even if there are no signs of a neoplastic process, one should be continue with medications, and annual gastroscopy should be performed.

The goals of drug therapy are:

  • normalisation of gastric juice acidity;
  • protection of oesophageal walls from irritating factors;
  • stimulation of cell regeneration;
  • reduction of cancer development risk.

Surgical treatment

Surgery is aimed at eliminating the backflow of gastric contents into the oesophagus. Indications for surgical procedure include:

  • lack of effect from medication;
  • esophageal sphincter dysfunction;
  • esophageal hernia signs.

Various techniques can be used to achieve the intended result:

  • Fundoplication. Consists in strengthening the sphincter by forming a cuff of gastric walls.
  • Cruroraphy. Invloves hernia gate closure.

After the operation, permanent drug therapy is prescribed.

Endoscopic treatment

If macroscopic changes in the esophageal tissue are detected, endoscopic resection is an option. The procedure is performed for both diagnostic and therapeutic purposes. It is advisable even if the histological findings do not show signs of neoplasia or cancer. This way one can determine the nature of the abnormal lesion and the stage of the disease.

At the resection site, ablation is performed to prevent further progression of the disease. Upon recovery, drug therapy with regular endoscopic examination are prescribed.

Preventive measures

The only reliable prevention of the disease is the timely detection of mucosal changes. Patients with GERD should take medications to reduce the level of gastric juice acidity and to protect the mucosa from negative effects. General recommendations include:

  • weight control;
  • giving up smoking;
  • a rational diet;
  • avoidance of strong alcohol.

Prognosis in Barrett's syndrome

It is impossible to foresee exactly how Barrett's oesophagus will develop in a particular patient. In some patients, the condition remains stable for a long time and examination does not reveal signs of malignization. In others, high-grade metaplasia is found several months after diagnosis. In low-grade metaplasia, regression often occurs.

Second opinion

The specific features of the disease are that it its symptoms are similar to GERD, it is hard to diagnose, and controversial treatment issues. Doctors who have not previously encountered Barrett's esophagus may not know its nuances. That is why it is worth seeking a second opinion when the disorder is suspected or treatment strategy is to be chosen.

Do not forget that qualified doctor advice can be obtained without visiting the clinic. The opinion of experienced specialists may be of use at any stage:

  • Diagnosis. The symptoms of the disease may be non-specific. An ill-informed doctor may miss important details. Additional consultation will help to assess the likelihood of the disease and, based on this, select the most informative methods of examination.
  • When assessing the results of diagnostics. The choice of Barrett's syndrome therapy directly depend on the accurate diagnosis, the stage, the lesion size and the nature of the mucosa alteration.
  • When choosing the treatment strategy. The experience of doctors in European clinics will help to choose the drugs or type of surgery.

All you need to get a second opinion is to provide all relevant medical records. Consultation is possible both in written format and as an online discussion.

The disease can hide behind the symptoms of GERD for a long time; moreover, the treatment of gastroesophageal reflux disease brings relief to the patient. But the precancerous condition requires monitoring, so patients with Barrett's oesophagus should regularly visit the doctor and carry out examinations. The choice of treatment including surgery options directly depends on the condition of the esophageal mucosa.

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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