Barrett's Oesophagus

                                               Barrett’s Oesophagus

The muscular tube carrying the food from the mouth to the stomach is called the esophagus. Here in this article, one of the most critical esophageal diseases is discussed, Barrett’s esophagus, named in honor of an Australian surgeon Norman Barrett.

It is a condition in which the flat epithelial lining of the esophagus becomes damaged by chronic acid reflux, which causes the epithelial lining to thicken, become red, and undergo dysplasia.

It is a precancerous condition with high chances of development of adenocarcinoma of the esophagus.

The lower esophageal sphincter (LES) between the stomach and the esophagus gets damaged due to overexposure of acidic stomach content. It begins to fail, leading to gastroesophageal reflux disease (GERD).

Cases of chronic and persistent GERD can induce changes in the lower esophagus’ epithelial lining, causing Barrett’s esophagus.

Pathophysiology

The development of Barrett’s esophagus takes place in two steps.

  • In the first step, the typical shape of the esophageal cell changes from flat, squamous epithelial cells to long, columnar epithelial cells. It occurs due to the repetitive episodes of acid reflux in a short period, usually in a year or so.
  • The second step involves replacing cells lining the stomach with the cells similar to the intestinal cells, a process known as intestinal metaplasia. This step is relatively slow as compared to the first one. Completion of this step leads to dysplasia and, consequently, to an increased incidence of adenocarcinoma of the esophagus.

Dysplasia

The word dysplasia is generally used to describe the existence of abnormal cells in a tissue or organ. However, it is always not cancerous, but should be taken care of. Its severity might vary depending upon the abnormality and the growth of the cells.

The tissue can be classified as having dysplastic cells as:

  • No dysplasia

Barrett’s esophagus is present, but no precancerous changes are found in the epithelial cells.

  • Low-grade dysplasia

Epithelial lining cells show small signs of precancerous changes.

  • High-grade dysplasia

Cells show many abnormal changes in size and shape. It is the final step before cancer development.

 Symptoms

Barrett’s esophagus symptoms are varied, ranging from mild to severe. Some of them are:

    • Heartburn
    • Indigestion
    • Nausea
    • Vomiting

Emergency symptoms:

Symptoms that indicate a more serious condition include:

    • Pain when swallowing food
    • Difficulty swallowing food (dysphagia)
    • Vomiting blood
    • Chest pain
    • Due to odynophagia, there is a loss in weight

Consult your general physician if you observe these symptoms or problems for more than two weeks.

Causes:

Gastro-esophageal reflux disease (GERD) is the leading cause of Barrett’s esophagus.

The risk of developing reflux is to a much larger scale if a person:-

    • Overweight.
    • Smoke.
    • Drink too much alcohol.
    • Eat spicy, acidic, or fatty foods.
    • Possess a hiatus hernia.

 

Diagnosis

  • Gastroscopy (endoscopy)

Patients suffering from severe acid reflux might undergo gastroscopy. To perform this test, a thin telescope is passed into the stomach through the esophagus, allowing the doctor or nurse to look inside.

The change in color of the lining of the lower esophagus from its regular pale white to a red color strongly suggests that Barrett’s esophagus has developed.

  • Biopsy

If Barrett’s esophagus is suspected during gastroscopy, several small biopsies are taken to lining the esophagus during the gastroscopy. These are then examined under microscopes in laboratories.

The metaplastic columnar cells confirm the diagnosis. The cells are examined further to observe the signs of dysplasia if present.

No dysplasia, if Barrett’s esophagus is present but no precancerous changes are found in the cells.

Low-grade dysplasia, if cells show small signs of precancerous changes.

High-grade dysplasia, if cells show many changes. High-grade dysplasia is thought to be the final step before cells change into esophageal cancer.

Management

Barrett’s esophagus treatment varies per its severity and symptoms. Broadly, it is divided into three main categories. 

  • Lifestyle changes
  • Medical treatment
  • Surgical treatment

Lifestyle changes

By making slight changes in lifestyle, acid reflux can be reduced. The following are listed some of these changes:

  • Eat small meals during the day
  • Do not eat for 2 to 3 hours before bedtime
  • Raise the head end of your bed by 10 to 20cm if you have reflux at night. By doing so, the stomach’s position is back to normal, and acid does not reach the esophagus. You can do this by putting something under your bed or mattress
  • Avoid spicy or fatty foods and alcohol. These may make symptoms worse
  • Keep to a healthy weight. If you are overweight, it may help to lose some weight
  • If you smoke, stop smoking.

Medical treatment

Acid suppression drugs are given to control the reflux esophagitis symptoms. Patients of GERD are on the proton pump inhibitor regimen for an extended period to control the symptoms and subsequent damage of acid reflux.

Symptoms of gastro-esophageal reflux disease are commonly controlled with the help of these drugs:

    • Proton pump inhibitors (PPIs)
    • Histamine receptor blockers.

They are usually prescribed in tablet form to be taken once a day. The dosage can vary according to the severity of the disease and must be taken after consulting the physician. Patients may take PPIs for the rest of their life depending upon their condition.

Pre-surgical evaluation

Screening and monitoring (surveillance)

If not controlled through treatment, patients undergo screening endoscopy, commonly recommended for males above 60 years. Among those not expected to live more than five years screening is not advised

After being diagnosed with Barrett’s esophagus, to monitor the condition, one is advised to take gastroscopy and biopsy at regular intervals, and this condition is called surveillance.

Each gastroscopy and biopsy may be conducted every two to three years if no dysplasia cells are detected. Once dysplasia is found, the check is advisable every year or so.

Surgical treatments

  • Fundoplication

For the treatment of GERD, this surgery, fundoplication, is performed. It is performed to:

  • Repair a hiatus hernia
  • Strengthen the valve at the bottom of the esophagus.

In this operation, the top part of the stomach is wrapped around the lower part of the esophagus. Then both the pieces are stitched together. It strengthens the valve at the lower end of the esophagus. It helps reduce acid reflux.

Laparoscopic fundoplication is the gold standard for GERD surgery. A fine tube called a laparoscope is used. With the aid of a laparoscope, instead of a big hole, few small incisions are made in the abdominal region. At times, laparotomy, in which one long incision is made, is also performed, depending on the severity and the grade of the disease.

  • Removing the affected area

The continuous abnormal changes in the esophageal cells are indicative of tumor development, either malignant or benign. The tumor, along with a margin of healthy tissue, is removed in a surgical procedure. Various methods can perform this.

A patient might undergo a single treatment or a series of procedures, depending upon the condition.

  • Endoscopic mucosal resection (EMR)

An EMR aims to remove the affected area of the esophagus lining, without damaging the rest of the esophagus. A thin wire called a snare is used for the removal of the affected part. It is placed through an endoscope into the affected area.

Mostly, patients with esophageal cancer and Barrett’s esophagus undergo EMR.

  • Radiofrequency ablation (RFA)

RFA uses heat to destroy abnormal cells. An electrode is passed into the esophagus with the help of an endoscope. The probe gives off electrical current (radio frequency) heating the abnormal or malignant cells to a high temperature destroying (ablating) the cell structure.

Patients usually have this treatment under a general anesthetic. Or may have a local anesthetic along with some medicine to make them drowsy (sedation).

Pain and irritation are the main side effects. Strong painkillers are prescribed to reduce pain. You might feel generally unwell and have a high temperature for a few days.

  • Oesophagectomy

It is an operation to remove part of the esophagus. Your surgeon may offer you this option if you have a high-grade dysplasia that cannot be removed using an endoscope.

The esophagus that contains the abnormal cells is removed, stitching the remaining portion with the stomach.  After this operation, you will probably spend a short time in the intensive care unit.

A thin tube, called a nasogastric tube, is inserted into the nose into the stomach or small intestine. It helps in the removal of digestive fluids. In the starting days, it might be difficult to swallow. You may also have a bad taste in your mouth.

An x-ray or an ultrasound is sometimes required to monitor the surgical area before starting meals. Slowly and gradually, the patient begins to eat normally.

Prognosis

Barrett’s esophagus is associated with esophageal adenocarcinoma of the junction (cancer of a lower part of the esophagus), having a death rate of 85%.

However, the development of esophageal cancer in patients with Barrett’s esophagus is much less than 6-7 per 1000 individuals. Most of the time, patients with esophageal adenocarcinoma can survive up to one year.

Prevalence of Barrett’s esophagus

Around 21% of the patients with normal acid reflux, asthma, and GERD issues are seen to be prevalent in this disease.

This prevalence rate can vary from 10% to 21%, depending upon the severity and the indication for endoscopic referral. Most of the patients with varying diseases suffer from Barrett’s esophagus.

Recently discovered treatments

Lately, there are new researches underway for the treatment of Barrett’s esophagus. Following are some of them:

    • Multipolar electrocoagulation
    • Cryotherapy

These treatments are only available as part of a clinical trial. The consulted doctor would suggest the kind of therapy that is suitable for you.

Areas of the disease needing further research

There are still some areas in the treatment of Barrett’s esophagus that need further research. On-time diagnosis is helpful in cancer research and treatment. Early diagnosis is accommodating in inventing methods of treatment without the use of endoscopy.

Breathe testing and saliva bio-markers are included in Barrett’s esophagus. A sponge, called cytosponge, is swallowed along with its string that expands in the stomach. The capsule collects esophageal cells and is pulled out of the patient’s gullet (esophagus)

Some other areas that need further researches are:

  • Specify the patients who mostly progress towards esophageal cancer.
  • Improvement in the quality of endoscopy
  • Advancement in the access of patients to specialist clinics and centers

Conclusion

Barrett’s esophagus is a pre-malignant condition and if treated before the development of cancer has a good survival rate. The leading cause of Barrett’s esophagus is chronic esophagitis due to GERD. Continuous acid reflux can lead to problems like Barrett’s esophagus, dysplasia and in severe cases, esophageal cancer. Timely intervention in GERD patients, prevents the development of Barrett’s esophagus and other subsequent complications.

Lifestyle adjustments with acid blockers is suitable for patients of mild GERD, but in severe cases, surgical options should be explored for long term results.

To avoid further complications, patients should take their symptoms seriously and should consult with their doctors on a regular basis. Barrett’s esophagus, if treated on time, is not a life threatening condition.