Patient information: Barrett's esophagus (Beyond the Basics)

BARRETT'S ESOPHAGUS OVERVIEW

The esophagus is the tube that connects the mouth with the stomach (figure 1). Barrett's esophagus occurs when the normal cells that line the lower part of the esophagus (called squamous cells) are replaced by a different cell type (called intestinal cells). This process usually occurs as a result of repetitive damage to the inside of the esophagus caused by longstanding acid reflux disease, called gastroesophageal reflux disease (GERD). In people with GERD, the esophagus is repeatedly exposed to excessive amounts of stomach acid. Interestingly, the intestinal cells of Barrett's esophagus are more resistant to acid than squamous cells, suggesting that these cells may develop to protect the esophagus from acid exposure. The problem is that the intestinal cells have a risk of transforming into cancer cells.

More detailed information about Barrett's esophagus is available separately. (See "Epidemiology, clinical manifestations, and diagnosis of Barrett's esophagus" and "Management of Barrett's esophagus".)

BARRETT'S ESOPHAGUS RISK FACTORS

There are a number of factors that increase the risk of developing Barrett's esophagus:

Age — Barrett's esophagus is most commonly diagnosed in middle-aged and older adults; the average age at diagnosis is approximately 55 years. Children can develop Barrett's esophagus, but rarely before the age of five years.

Gender — Men are more commonly diagnosed with Barrett's esophagus than women.

Ethnic background — Barrett's esophagus is most common in white populations, less common in Hispanic populations, and uncommon in Asian and black populations.

Lifestyle — Smokers are more commonly diagnosed with Barrett's esophagus than nonsmokers.

BARRETT'S ESOPHAGUS SYMPTOMS

Barrett's esophagus itself produces no symptoms. Instead, most people seek help because of symptoms of GERD, including heartburn, regurgitation of stomach contents, and, less commonly, difficulty swallowing.

BARRETT'S ESOPHAGUS DIAGNOSIS

A healthcare provider may suspect Barrett's esophagus based upon a person's symptoms and the risk factors described above. An endoscopy is needed to confirm the abnormal esophageal lining.

Upper endoscopy — Upper endoscopy is a test that allows your doctor to see the inside of the esophagus and stomach. Before the test, you are sedated to prevent discomfort. The doctor will insert a thin lighted tube into the esophagus. The tube has a camera, which allows the doctor to see the lining of the esophagus.

Normally, the lining should appear pale and glossy; in a person with Barrett's esophagus, the lining appears pink or red and velvety. The doctor will remove a small sample of the lining (a biopsy) during the endoscopy so that it can be examined with a microscope for signs of Barrett's. (See "Patient information: Upper endoscopy (Beyond the Basics)".)

Endoscopy detects most (80 percent) but not all cases of Barrett's esophagus. Individual variations in the anatomy of the esophagus and the area where it meets the stomach can make the diagnosis of Barrett's esophagus difficult in some people.

BARRETT'S ESOPHAGUS TREATMENT

The goal of treatment in patients with Barrett's esophagus is to control reflux symptoms. Aggressive reflux treatment may be more effective in preventing cancer than treating only when there are reflux symptoms. (See "Management of Barrett's esophagus".)

Behavior and diet changes — The first priority in treating Barrett's esophagus is to stop the damage to the esophageal lining, which usually means eliminating acid reflux. Most patients are advised to avoid certain foods and behaviors that increase the risk of reflux. Foods that can worsen reflux include:

Chocolate

Coffee and tea

Peppermint

Alcohol

Fatty foods

Acidic juices such as orange or tomato juice may also worsen symptoms. Carbonated beverages can be a problem for some people. (See "Patient information: Acid reflux (gastroesophageal reflux disease) in adults (Beyond the Basics)".)

Behaviors that can worsen reflux include eating meals just before going to bed, lying down soon after eating meals, and eating very large meals. Placing bricks or blocks under the head of the bed (to raise it by about six inches) help to keep acid in the stomach while sleeping. It is not helpful to use additional pillows under the head.

Medications — A clinician may prescribe medications that reduce the amount of acid produced by the stomach. A class of medications called proton pump inhibitors is commonly recommended. Five different formulations (some of which are available as a generic) are currently available: omeprazole (Prilosec), esomeprazole (Nexium), lansoprazole (Prevacid), rabeprazole (Aciphex) and pantoprazole (Protonix); any of these is an acceptable option.

Surgery — People who have severe reflux may benefit from surgical procedures to reduce reflux. Surgery is not the best treatment in all situations, so you should discuss this option with your doctor. More information about surgical treatments for reflux is available in a separate topic review. (See "Patient information: Acid reflux (gastroesophageal reflux disease) in adults (Beyond the Basics)".)

BARRETT'S ESOPHAGUS COMPLICATIONS

One potential complication of Barrett's esophagus is that, over time, the abnormal esophageal lining can develop early precancerous changes. The early changes may progress to advanced precancerous changes, and finally to frank esophageal cancer. If undetected, this cancer can spread and invade surrounding tissues.

However, progression to cancer is uncommon for any individual patient; studies that follow patients with Barrett's esophagus reveal that fewer than 0.5 percent of patients develop esophageal cancer per year. Furthermore, patients with Barrett's esophagus appear to live approximately as long as people who are free of this condition. Patients often die of other causes before Barrett's esophagus progresses to cancer.

BARRETT'S ESOPHAGUS MONITORING

Monitoring for precancerous changes is recommended for most patients with Barrett's esophagus. At this time, monitoring includes periodic endoscopy with tissue biopsy. (See "Patient information: Upper endoscopy (Beyond the Basics)".)

Although new technologies for monitoring are on the horizon, most are still considered to be experimental. Experts do not agree about the usefulness of monitoring. The benefits of monitoring depend upon each person's chance of developing esophageal cancer, which may be difficult to determine.

Benefits — Reasons to perform endoscopic monitoring include:

Monitoring can detect precancerous changes (dysplasia) in the esophageal lining. These changes may indicate that the person has an increased risk of cancer. Early detection may be especially important for younger patients.

Monitoring may detect cancer at an earlier stage, when it can be more effectively treated.

Limitations — However, not all patients will benefit from endoscopic monitoring.

Progression of Barrett's esophagus to cancer is uncommon.

Endoscopy carries certain risks and often causes anxiety.

Endoscopy may miss areas with premalignant changes or cancer.

Even if endoscopy detects cancer, the available treatment options may have unacceptably high risks.

PRECANCEROUS CHANGES AND BARRETT'S ESOPHAGUS

Confirmation and staging — If precancerous changes are discovered, they should be confirmed by a second pathologist, an expert in examining tissue samples. It is sometimes difficult to correctly identify precancerous changes, especially when there is inflammation (usually caused by the ongoing reflux of acid). Many clinicians increase the dose of acid-suppressing medications in this situation.

The precancerous changes must then be graded as "low-grade dysplasia" or "high-grade dysplasia," depending upon their severity.

Treatment options — People with low-grade dysplasia are often told to increase their dose of acid suppressing medication and undergo a repeat endoscopy within 6 to 12 months. The management of low-grade dysplasia is especially controversial. Some physicians recommend frequent endoscopic surveillance for patients with low-grade dysplasia, while others recommend destroying the abnormal tissue with radiofrequency ablation (see below).

A person with high-grade dysplasia has more limited options. The management of this condition is controversial. The optimal treatment depends upon the person's age and health and the patient and physician's preference. The options include removal of the esophagus (esophagectomy) and removing (eg, endoscopic mucosal resection) or destroying (eg, radiofrequency ablation, photodynamic or other ablation therapies) the abnormal tissue using endoscopic techniques.

Esophagectomy — In removing the esophagus, esophagectomy removes all of the precancerous tissue and some of the lymph nodes near the esophagus. However, this treatment has higher rates of procedure-related death and long-term complications than the endoscopic treatments for dysplasia.

Esophagectomy is not necessary in most patients who have dysplasia in Barrett’s esophagus. In some patients, however, it may not be possible to destroy all of the abnormal tissue by endoscopic treatments, and esophagectomy may be recommended for those patients. Esophagectomy should be performed by an experienced physician in a hospital where the procedure is performed frequently. In one study of 340 esophagectomies performed at 25 different hospitals, the mortality rate was 3 percent for patients who had the operation at institutions that did five or more esophagectomies per year, compared to 12 percent for patients treated at institutions where the operation was performed less frequently [1].

Endoscopic treatments — Endoscopic treatments are usually recommended for patients with high-grade dysplasia.

Endoscopic mucosal resection — Endoscopic mucosal resection (EMR) involves the removal of a large but thin area of esophageal tissue through an endoscope. EMR provides large tissue specimens that can be examined by the pathologist to determine the character and extent of the abnormality and determine if an adequate amount of tissue was removed. Therefore, it can help to confirm the person's diagnosis and completely treat the abnormality (if the abnormal tissue is removed completely). However, this technique is generally performed only in specialized centers. Generally, EMR is performed if the endoscopist sees an area of nodularity in the Barrett’s esophagus. EMR is commonly followed by ablation of the remaining Barrett’s esophagus, usually with radiofrequency ablation (see below).

Radiofrequency ablation — Radiofrequency ablation (RFA) is an endoscopic procedure that uses radiofrequency energy (microwaves) to destroy the Barrett’s cells. In short-term studies, RFA has been shown to prevent high-grade dysplasia from progressing to cancer and to prevent low-grade dysplasia from developing more advanced features. However, there is limited information on the long-term outcome of this approach. In up to 5 percent of patients, the procedure causes a complication, such as narrowing of the esophagus, which may require repeated treatments to open the esophagus.

Another concern with RFA is that, in a small minority of patients with high-grade dysplasia (less than 2 percent), there may be cancer in the lymph nodes adjacent to the esophagus. RFA cannot cure cancer in the lymph nodes. In all cases, the patient and family should discuss the risks and benefits of possible treatments with a healthcare provider.

Photodynamic therapy — Photodynamic therapy is a treatment that uses chemical agents, known as photosensitizers, to kill certain types of cells (such as Barrett's cells) when the cells are exposed to laser light. Patients are given the photosensitizer medication into a vein and then undergo endoscopy. During the endoscopy, a laser light is used to activate the photosensitizer and destroy the Barrett's tissue.

However, there is limited information on the long-term outcome of this approach. Furthermore, photodynamic therapy is expensive and available in only a small number of academic medical centers. In up to 40 percent of patients, the procedure causes a complication, such as narrowing of the esophagus, which may require repeated treatments to open the esophagus.

Another concern with photodynamic therapy is that patients with high-grade dysplasia may have areas of invasive cancer that are not treated adequately. Photodynamic therapy has largely been replaced by RFA, which appears to be safer and at least as effective. In all cases, the patient and family should discuss the risks and benefits of possible treatments with a healthcare provider.

SUMMARY

Despite the uncertainties surrounding the monitoring and treatment of Barrett's esophagus, there is consensus on one matter: The available options should be tailored to the individual patient. The following are general guidelines:

People with Barrett's esophagus should be treated to decrease reflux symptoms. This may improve or eliminate symptoms of heartburn, reduce inflammation, help prevent complications, and improve the accuracy of endoscopy results.

People without evidence of precancerous changes (ie, no dysplasia) or esophageal cancer should have endoscopy performed every three to five years to look for the development of precancerous changes, unless there are other medical conditions that increase the small risks usually associated with endoscopy.

If endoscopy reveals a precancerous change (dysplasia), this finding should be confirmed by at least one expert; if necessary, additional tissue samples should be collected to resolve any doubt.

People with early precancerous changes (low-grade dysplasia) often are advised to have repeat endoscopy at 6 and 12 months, followed by annual endoscopy if the lesion does not appear to progress. In some cases, RFA may be considered to treat low-grade dysplasia.

People with advanced precancerous changes (high-grade dysplasia) should have their diagnosis confirmed by an expert. If the diagnosis is confirmed, treatment usually involves a combination of EMR and RFA.

WHERE TO GET MORE INFORMATION

Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient information: Acid reflux (gastroesophageal reflux disease) in adults (The Basics)
Patient information: Barrett's esophagus (The Basics)
Patient information: Esophageal cancer (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient information: Upper endoscopy (Beyond the Basics)
Patient information: Acid reflux (gastroesophageal reflux disease) in adults (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Autofluorescence endoscopy for Barrett's esophagus
Endoscopic resection for treatment of high-grade dysplasia and early cancer in Barrett's esophagus
Epidemiology, clinical manifestations, and diagnosis of Barrett's esophagus
Management of Barrett's esophagus
Narrow band imaging in Barrett's esophagus
Pathogenesis of Barrett's esophagus and its malignant transformation
Photodynamic therapy for ablation of Barrett's esophagus
Radiofrequency ablation for Barrett's esophagus

The following organizations also provide reliable health information.

National Library of Medicine

     (www.nlm.nih.gov/medlineplus/healthtopics.html)

The American Gastroenterological Society

     (www.gastro.org)

The American College of Gastroenterology

     (www.acg.gi.org)

The American Society for Gastrointestinal Endoscopy

     (www.asge.org/patients/patients.aspx?id=8954)

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Literature review current through: Jul 2014. | This topic last updated: Jul 18, 2013.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2014 UpToDate, Inc.
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All topics are updated as new information becomes available. Our peer review process typically takes one to six weeks depending on the issue.