Diseases & Conditions

Barrett's esophagus

Barrett's esophagus is a condition in which the color and composition of the cells lining your lower esophagus change because of repeated exposure to stomach acid. This exposure to stomach acid is most often a result of long-term gastroesophageal reflux disease (GERD) — a chronic regurgitation of acid from your stomach into your lower esophagus.

Barrett's esophagus is uncommon. Only a small percentage of people with GERD develop Barrett's esophagus. But once Barrett's esophagus is diagnosed, there's a greater risk of developing esophageal cancer. Although increased, the absolute risk of esophageal cancer for someone with Barrett's esophagus is small — less than 1 percent a year.

You can eliminate or reduce the frequency of stomach acids flowing up into the lower end of your esophagus — and your chance of developing Barrett's esophagus — by making lifestyle changes.

The exact cause of Barrett's esophagus is not known, but the condition usually develops in people who have GERD. Heartburn and acid reflux are the most common symptoms of GERD and result from stomach contents washing back into the esophagus.

The ring of muscle at the junction of the esophagus and stomach (sphincter) normally keeps acid in your stomach by closing tight. GERD usually results from a weakened sphincter, and it can be aggravated by a protrusion of the upper stomach through the diaphragm (hiatal hernia).

Left untreated, GERD can lead to more-serious complications. Severe heartburn with inflamed esophageal tissue (esophagitis) can cause chest pain intense enough to resemble a heart attack. Other complications of GERD may include esophageal stricture — in which scarring causes narrowing of the esophagus — bleeding, Barrett's esophagus and esophageal cancer.

Diagnosing Barrett's esophagus is difficult because it often doesn't exhibit specific symptoms. Experiencing the frequent and severe acid reflux of GERD may be the best indication that you either have Barrett's esophagus or may be at risk of the disease.

If you have severe acid reflux or have had acid reflux for many years, your doctor may discover Barrett's esophagus by examining your esophagus through endoscopy. Endoscopy involves inserting a lighted, flexible tube (endoscope) with a camera on its tip through your mouth and into your esophagus and stomach. Usually, you'll receive a local anesthetic, and you may be sedated for this procedure.

What your doctor looks for
The procedure allows your doctor to search for abnormalities such as precancerous cell changes (dysplasia) or an abnormal junction between your stomach and esophagus. In a healthy esophagus, the stomach-esophagus mucosal junction is at the lower end of the esophagus. In Barrett's esophagus, this junction is displaced upward. If Barrett's esophagus is suspected, your doctor also looks for evidence of cancer or precancerous changes.

During endoscopy, your doctor may remove tissue samples (biopsies) of potentially abnormal areas to be examined under a microscope. If specimens reveal intestinal goblet-shaped cells not usually seen in the esophagus, your doctor may make a diagnosis of Barrett's esophagus.

Following your diagnosis, your doctor may recommend endoscopies at regular intervals to screen for cell changes that could indicate progression to cancer. This usually means a repeat endoscopy one year after your diagnosis, followed by endoscopies every three years if no dysplasia is present. If a tissue sample shows dysplasia, you may need screenings at shorter intervals — at least annually and in some cases, as often as every three months.

Having Barrett's esophagus increases your risk of developing esophageal cancer. The earlier that metaplasia — the telltale changing of the color of the tissue that lines the lower esophagus from its normal pink to a salmon color — 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 from the esophagus to nearby lymph nodes and to other parts of your body. If high-grade dysplasia is present, your doctor will likely order more tests such as a CT scan of the chest and abdomen and an endoscopic ultrasound to look for signs of cancer. An endoscopic ultrasound is similar to an endoscopy but allows your doctor to better examine the wall of the esophagus and surrounding lymph nodes using sound waves. Biopsies of suspicious lymph nodes can be done during the procedure.

The primary goal of Barrett's esophagus treatment is to prevent the development of esophageal cancer. It's not too late to treat dysplasia in Barrett's esophagus if it hasn't yet advanced to cancer.

Treatment for Barrett's esophagus may start with controlling GERD by making a number of lifestyle changes and taking self-care steps. These actions include losing weight, avoiding foods that aggravate heartburn, stopping smoking if you smoke, taking antacids or stronger acid-blocking medications, and elevating the head of your bed to prevent reflux during sleep.

People with severe GERD and Barrett's esophagus usually need aggressive treatment, which may include medications, other nonsurgical medical procedures or even surgery.

Medications
Medications to treat GERD and Barrett's esophagus include:

• Proton pump inhibitors (PPIs). These medications — such as omeprazole (Prilosec), lansoprazole (Prevacid), rabeprazole (Aciphex), pantoprazole (Protonix) and esomeprazole (Nexium) — block production of acid and relieve irritated tissue.
• H-2-receptor blockers. Doctors sometimes prescribe this class of drugs to treat GERD and Barrett's esophagus. They're less expensive, although weaker than PPIs. Prescription H-2-receptor blockers such as famotidine (Pepcid AC), cimetidine (Tagamet), nizatidine (Axid AR) and ranitidine (Zantac 75) are also available over-the-counter in doses less than prescription strength.

Although these medications often are quite effective for GERD, once Barrett's metaplasia is present these drugs won't reliably reverse the condition, and the risk of cancer remains even if your GERD symptoms go away with treatment.

Surgery
Anti-reflux surgery (laparoscopic Nissen fundoplication) offers an alternative to long-term use of medication for GERD. The procedure tightens the sphincter by wrapping part of the stomach around the lower esophagus to prevent acid reflux. Laparoscopic surgery involves inserting special instruments through small incisions — less than an inch. The procedure leaves only tiny scars. You can expect to stay in the hospital for one or two days after this surgery. Although surgery can be effective for GERD, once Barrett's metaplasia is present surgery won't reliably reverse the condition, and the risk of cancer remains.

If you have esophageal cancer, or if you have Barrett's esophagus and high-grade dysplasia, your doctor may recommend you undergo a major surgical procedure in which the esophagus is removed completely and the stomach is pulled into the chest (esophagectomy). You may need to spend about two weeks recovering in the hospital after surgery. Although this treatment is effective, it is associated with significant health risks. Up to 50 percent of people who undergo esophagectomy experience at least one serious complication, including pneumonia, heart attack and infections at the surgical site.

The surgical treatment of people with high-grade dysplasia is controversial. Some experts believe that esophagectomy should be used as a measure to protect against cancer. Other experts believe that it's sufficient to schedule screening endoscopies every three to six months and perform an esophagectomy only if cancer develops. Doctors generally don't recommend surgery for people with declining health or for those who are too weak to withstand this major procedure.

Alternatives to medications and surgery
Removal (ablation) of dysplasia makes possible the reversal of Barrett's esophagus, and it may prevent esophageal cancer. Combined with PPIs, ablation may be appropriate especially if you're not a good candidate for an esophagectomy. Ablation procedures include:

• Photodynamic therapy (PDT). First, you'll be injected with a drug called porfimer sodium (Photofrin) that makes the Barrett's cells sensitive to light. Then, your doctor inserts a specialized light source into your esophagus. The light causes a reaction with the Photofrin that destroys Barrett's cells.
• Electrocautery. Your doctor inserts an electric wire into your esophagus to burn away dysplasia.
• Laser therapy. Your doctor uses a hot beam of light (laser) inserted into your esophagus to burn away Barrett's cells.
• Argon plasma coagulation. Your doctor releases a jet of argon gas into your esophagus along with an electric current to burn away dysplasia.
• Endoscopic mucosal resection. Using an endoscope, your doctor injects a saline solution under the area of your esophagus that contains dysplasia. A blister forms under these abnormal cells, allowing your doctor to cut or suction the abnormal area away from the underlying tissue without damaging the rest of your esophagus. Your doctor may recommend following this procedure with photodynamic therapy.

• Radiofrequency ablation. During this procedure, your doctor guides a tiny camera and a small balloon down your esophagus. The balloon and camera help your doctor measure the size of your esophagus and the length of the area that needs treatment. Then, your doctor inserts a second balloon, specifically sized to fit the area requiring treatment. The second balloon delivers a short burst of energy that burns out (ablates) the dysplasia.

  Radiofrequency ablation is a fairly new procedure that is still being studied. However, research shows that more than 70 percent of those treated are free of dysplasia up to 12 months after treatment. Complications can include esophageal perforation (rupture) and strictures (narrowing).

The long-term effectiveness of ablation procedures in preventing cancer is still being studied.