Barrett's Oesophagus

What is Barrett’s oesophagus? 

Barrett’s oesophagus is a condition where the cells lining the inner surface of the oesophagus (termed the epithelial layer) transform from normal oesophageal cells into those resembling stomach or intestinal lining cells. 

 

What causes Barrett’s oesophagus to develop?

Barrett’s oesophagus develops in response to longstanding acid reflux (GORD) in the oesophagus. The change in oesophageal lining cells starts at the bottom end of the oesophagus (because this is the area most heavily exposed to acid reflux from the stomach) and progresses for varying lengths up the oesophagus.

 

What are the consequences of Barrett’s oesophagus?

On its own, Barrett’s oesophagus does not lead to change in the patient’s symptoms, and does not directly cause the patient harm. The importance of Barrett’s oesophagus lies in the fact that it increases the risk of developing cancer of the oesophagus.

 

What are the risks of developing cancer from Barrett’s oesophagus?

Patients with Barrett’s oesophagus have a higher risk of developing cancer of the oesophagus than the general population. Cancer of the oesophagus is a deadly disease that carries a poor prognosis. However, only a small number of Barrett's patients will develop cancer each year. The yearly risk of developing cancer amongst patients with Barrett’s oesophagus approximates 0.25%. Expressed in other terms, one out of every 400 patients with Barrett’s oesophagus will develop oesophageal cancer each year. A significant proportion of patients with Barrett’s will never develop oesophageal cancer. 

 

However, not all Barrett’s is alike, and the risks of developing cancer can vary based on several factors. Short segments of Barrett’s (less than 3cm in length) carry lower risk of cancer than longer segments (longer than 3cm). Most importantly, the presence of dysplasia (further mutations in the oesophageal lining cells that are another step towards cancer) significantly increases the risk of cancer. When Barrett’s with high-grade dysplasia is present, the risk of cancer becomes much higher at 6% per year.  

 

Are there symptoms of Barrett’s oesophagus?

The development of Barrett’s oesophagus itself does not cause any new symptoms. However, because Barrett’s occurs in response to longstanding acid reflux, most patients with Barrett’s oesophagus (but not all) have symptoms of acid reflux, i.e. heartburn and regurgitation. Based on symptoms alone, it is impossible to distinguish between GORD with Barrett’s oesophagus vs GORD without Barrett’s.

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Risk factors for Barrett’s oesophagus

While longstanding acid reflux (GORD) is thought to be the cause of Barrett’s oesophagus, not all patients with GORD will develop Barrett’s oesophagus. There is no way of predicting exactly which patients with GORD will develop Barrett’s oesophagus. However, several factors make the development of Barrett’s oesophagus more likely:

• Male sex

• Overweight or obesity

• Caucasian ethnicity

• Cigarette smoking

• Age over 50 years

 

If multiple risk factors are present in a patient with longstanding reflux symptoms, it is more important to investigate with endoscopy.

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How do I know if I have Barrett’s oesophagus? How is it diagnosed?

At present, the only way to definitively determine if a patient has Barrett’s is to perform an upper GI endoscopy (gastroscopy). The characteristic changes in the lining cells of the lower oesophagus can be visualised during endoscopy as a salmon pink colour in this region. If Barrett’s is suspected by the endoscopist, a close visual inspection should be made to look for the presence of any oesophageal cancer or precancerous changes within the Barrett’s segment. As well as inspection under normal light, an experienced gastroenterologist will take a second look at the area of Barrett’s under a special light filter which can pick up subtle abnormalities. The segment of Barrett’s can be sprayed with acetic acid through a channel within the endoscope to further improve visualisation of abnormalities.

 

The segment of Barrett’s oesophagus is then carefully biopsied via instruments inserted through the endoscope. The final diagnosis of Barrett’s always needs to be made by a pathologist after examination of the biopsy specimens under the microscope. 

 

How is Barrett’s oesophagus treated?

• Acid suppressing medications: Proton pump inhibitors (e.g. Nexium, Somac, Losec, Pariet and others) are generally prescribed to all patients with Barrett’s oesophagus. This is due to the belief that they may reduce the risk of progression to cancer, by reducing the amount of acidic fluid refluxing into the oesophagus (although this has never been conclusively proven). Further, they are overall safe medications to use long term and have the added benefit of reducing reflux symptoms in patients with Barrett’s. 

• Monitoring and surveillance: All patients with Barrett’s oesophagus should receive regular surveillance endoscopies, due to the risk of cancer developing. By scheduling regular endoscopies, we can not only find cancers early (when they are likely to be curable), but detect precancerous changes that can be treated to prevent cancer developing at all. The interval between surveillance endoscopies can vary, and is dependent on specific characteristics of your Barrett's segment.

 

The majority of patients with Barrett’s oesophagus do not require any other specific form of therapy. However, in those where dysplasia (more concerning precancerous change) has developed, more aggressive therapy is warranted due to the markedly higher risk of cancer in such patients. While in the past such patients required extensive surgery, nowadays Barrett’s patients who have dysplasia present are generally managed with endoscopic eradication therapy:

• Barrett’s endoscopic eradication therapy: Consists of multiple modalities of treatment all delivered via endoscopy. Any visible nodules or lumps (which often harbour early cancerous changes) within the Barrett’s segment are excised using rubber-band assisted ligation techniques (endoscopic mucosal resection). Non-lumpy or ‘flat’ areas of the Barrett’s segment are then ablated or ‘burnt off’ using a technique called radiofrequency ablation. After the Barrett’s cells are burnt off, new, healthy oesophageal lining tissue is encouraged to grow back by suppressing stomach acid production.

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Who looks after patients with Barrett’s oesophagus?

All patients with Barrett’s oesophagus should be treated by a Gastroenterologist with expertise in oesophageal disorders. Contact A/Prof Santosh Sanagapalli today to ensure that your condition is handled with expert care.