Barrett's Esophagus (Some Things You
What is Barrett's Esophagus?
Barrett's esophagus is a condition which may occur in as many as 10% of
patients with severe gastroesophageal reflux. As a result of chronic
long-standing acid reflux, the normal lining of the lower esophagus is
severely damaged or destroyed. The lining of the stomach then grows into
the esophagus to replace the normal lining. Unfortunately, this lining is
abnormal. It undergoes a change called intestinal metaplasia, which can be
positively identified on biopsy. Further changes such as dysplasia may
occur which lead to the development of esophageal cancer in up to 5-10% of
patients with this condition. If Barrett's esophagus is identified, the
patient should be followed regularly with periodic gastroscopy and
biopsies. The goal of screening is to identify cancer at an early stage to
improve the chances of a surgical cure.
Endoscopic Screening and Dysplasia
Once a year, patients with Barrett's esophagus should undergo gastroscopy.
When the examination is performed, the Barrett's mucosa is carefully
examined and any suspicious areas are biopsied. Random biopsies are also
taken. All the biopsies are carefully examined for signs of dysplasia or
cancer. Dysplasia is a precancerous change which usually occurs before
cancer ever develops. It can be thought of as an early warning signal, but
does not always progress to cancer.
If cancer is found, the patient will undergo preoperative evaluation and
will be referred for surgery. This is a major operation to remove the
cancer and all the Barrett's mucosa. As a general rule, early cancers
detected in patients screened regularly are very likely to be cured. This
is a significant improvement over the usual outcome for patients with
esophageal cancer. Overall, 95% of these patients will die within 5 years.
Esophageal cancer is a very serious and potentially lethal disease. Our
sincere hope is that with careful screening and follow-up, we will be able
to decrease the risk of death from esophageal cancer in this group of
What if Dysplasia is Found?
If moderate or severe dysplasia is found, the patient will be rescoped
within a few weeks. Additional biopsies are taken to make sure a small
cancer was not missed during the examination. If severe dysplasia
persists, there is a high risk of progression to cancer. These patients
need to be followed very closely and may need to undergo surgery, even if
definite cancer is not found at endoscopy.
Mild dysplasia is seen more frequently and is less cause for concern.
Chronic reflux results in inflammation and damage to cells lining the
esophagus. The rapid repair and regeneration which occurs in response to
inflammation can often be mistaken for dysplasia. If mild dysplasia is
found, the patient is placed on medical treatment with omeprazole
(Prilosec) 20 mg twice a day to completely turn off acid production by the
stomach. Repeat gastroscopy and biopsy is performed after three months.
If mild dysplasia recurs, or if there is progression to moderate or severe
dysplasia, screening is continued at three-month intervals. If mild
dysplasia disappears, the patient returns to the schedule of annual
screening. If not, then endoscopy and biopsy should continue to be
performed at three to six month intervals.
Most, if not all, patients with Barrett's esophagus should be on medication
to reduce the amount of acid secreted by the stomach. Treatment aids in
the relief of symptoms and may also reduce the risk of forming a stricture
or ring of scar tissue. Strictures are the most common cause of swallowing
problems in patients with Barrett's. If you begin to experience choking or
difficulty swallowing, seek medical attention immediately. This could also
be a symptom of esophageal cancer.
The other argument in favor of chronic medical therapy is the relationship
between inflammation and cancer. In many forms of cancer, chronic
inflammation and tissue damage over many years leads to the development of
cancer. In Barrett's esophagus, inflammation is a result of chronic acid
reflux. Even if you have no symptoms, you should follow our
recommendations for patients with heartburn. Daily use of medications to
reduce stomach acid production is also desirable.
Some patients with Barrett's esophagus have very little heartburn, even
though they are experiencing severe reflux and have significant
inflammation. This is in contrast to the person with reflux and minimal or
no inflammation who complains of severe heartburn. The difference is the
level of acid sensitivity. Persons with severe reflux and an esophagus
which is not acid sensitive are more likely to develop and an esophageal
stricture or even Barrett's esophagus. This is because they are less
likely to seek treatment for reflux symptoms. The goal of medical therapy
is prevention of inflammation, scar tissue and cancer of the esophagus.
copyright 1995 Digestive Health Specialists, P.A.
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Heartburn, Reflux, and Esophagitis
Swallowing Disorders and Hiatal Hernia