We don’t really know why Barrett’s esophagus develops in response to acid injury. It may be the body’s attempt to protect your esophagus from chronic acid reflux. Because Barrett’s esophagus produces mucous, it might help the esophagus resist acid injury better than the normal squamous lining. Some Barrett’s patients report that their heartburn symptoms actually IMPROVED after the development of Barrett’s. This leads some researchers to believe that the development of Barrett’s esophagus may help to relieve GERD in some people.
Anyone can develop Barrett’s esophagus. However, the typical patient is a middle-aged or elderly Caucasian or Hispanic male who has a long history of heartburn. Women can also develop Barrett’s esophagus, but men outnumber women by a ratio of 4:1. In addition, men are eight times more likely to develop esophageal adenocarcinoma (Barrett’s-related cancer) as women. Barrett’s esophagus and related cancer are much less common among minority populations, however, it’s important to note that ANYONE of any age, race, or gender can develop Barrett’s.
Although we don’t know why Caucasian and Hispanic men are more likely to develop Barrett’s, we do know that there are several associated risk factors, including chronic heartburn, obesity, age, and family history.
Does this mean I will eventually develop Barrett’s esophagus?
Definitely not. It’s encouraging to note that the majority of people with heartburn will never develop Barrett’s esophagus. Most studies report that about 10% - 20% of people with reflux have Barrett’s. Unfortunately, there is no good way to know if a patient has Barrett’s without looking directly at the esophagus during an upper endoscopy.
The ONLY way to positively diagnose Barrett’s esophagus is through a procedure called EGD or upper endoscopy with biopsy. Barrett’s esophagus is commonly diagnosed as part of an evaluation of chronic heartburn or other complaints such as gastrointestinal bleeding or dysphagia (food getting stuck in the esophagus). Doctors sometimes refer patients for an upper endoscopy because medication failed to relieve the patient’s heartburn symptoms.
Unfortunately, most patients who have Barrett’s esophagus never see a doctor for their heartburn symptoms. Most patients with esophageal cancer were never aware they may have had underlying Barrett’s esophagus for years. As we become more aware of Barrett’s esophagus as a complication of heartburn, more patients may seek medical attention for their heartburn or be referred by their physicians for an upper endoscopy. Official guidelines suggest that patients who have a history of GERD for at least five years, and are age 50 or older, undergo an upper endoscopy to look for Barrett’s esophagus. There are many exceptions to this rule including almost any patient with either longstanding heartburn or unusually severe GERD symptoms. It is not unusual to diagnose Barrett’s esophagus in individuals in their 30’ and 40’s if they have had a long history of severe reflux symptoms.
Esophagogastroduodenoscopy (EGD) with biopsy, also known as upper endoscopy, is a test that involves passing an endoscope, a long, flexible black tube with a light and video camera on one end, through the mouth to examine the esophagus, stomach, and the first part of the small intestine, called the duodenum.
An EGD is performed in a hospital or private endoscopy center by a gastroenterologist (GI or intestinal doctor). You will be put under “conscious sedation” rather than general anesthesia. In most centers, you will be put totally to sleep and will not remember anything from your procedure. Some hospitals and centers use a lighter sedation and the patient may have some memory of the exam. As with general anesthesia, your heart rate, blood pressure and oxygen levels will be checked regularly.
After sedation, the doctor will pass the endoscope through your mouth into the back of your throat. Most people spontaneously swallow even when asleep, and the scope is easily passed into the esophagus. Using the endoscope, the doctor can see a magnified picture of the lining of the upper intestinal tract on a video monitor. Air, water, and suction can be used through the scope so that the doctor can get a thorough look at the upper GI tract lining.
The typical EGD procedure lasts about 5 to 10 minutes. After the EGD procedure is over, you will be given the results of the observations, but will have to wait on biopsy results until the histologic analysis is completed. Because of the sedation, you will need someone to drive you home after the procedure.
EGD is very safe, has a low risk of complications, and is one of the most frequently performed endoscopic procedures.
For years, the only therapy to completely cure Barrett’s esophagus was surgical removal of the esophagus (esophagectomy). Today, esophagectomy is reserved for patients who have Barrett’s with high-grade dysplasia or cancer, and is not recommended for patients who have Barrett’s esophagus alone. This is because esophagectomy has a considerable risk of death and later complications due to the procedure. Esophagectomy should be done by experienced surgeons in a high volume center that perform this surgery on a regular basis.
Fortunately, studies indicate that most patients who have Barrett’s esophagus do not develop esophageal cancer, but the risk is always there. Over the past several years , researchers have been exploring ways to remove Barrett’s esophagus without surgery. There are now several promising methods for treating and eliminating Barrett’s with minimal risk to the patient. For that reason, many physician are recommending these less invasive therapies in earlier stages of Barrett’s with the hope of reducing the risk of cancer later in life. There are now several new options to consider for the treatment of Barrett’s esophagus that are non-surgical. The most promising therapy may be endoscopic ablation using a device known as the Halo 360. Other promising techniques are listed below.
After a diagnosis of Barrett’s esophagus, patients are usually placed on a strong anti-acid, as well as an anti-reflux diet and lifestyle. These patients usually return for repeat evaluation in six months. At the six-month exam, patients will have extensive sampling of the Barrett’s mucosa to look for the presence of dysplasia within the Barrett’s. Based on these biopsy findings, a surveillance strategy is chosen with upper endoscopy as frequently as every three months, to as infrequently as every three years. This will be decided by your gastroenterologist.
Until recently, there has been no real treatment for Barrett’s other than careful monitoring and management of the patient for cancer. Patients have been monitored with periodic upper endoscopies and given medication to help relieve heartburn symptoms. The problem with this type of management is that Barrett’s patients must undergo a lot of inconvenience and discomfort associated with lifelong endoscopies, without the benefit of treating the underlying condition.
The good news is that now there are several new non-surgical endoscopic therapies that are used to remove abnormal Barrett’s tissue. These include endoscopic ablation Halo 360 (Barrx Medical Inc, Sunnyvale Ca), EMR(endoscopic mucosal resection-Duette Multiband Ligator-Wilson Cook), and other therapies, such as APC(argon plasma caogulation-ERBE Elektromedizin GmbH), and PDT(photodynamic Therapy-Photofrin-Axcan Pharma),. Each of these unique therapies has its own advantages, disadvantages, and success rates. You will need to discuss these options with a gastroenterologist that has a particular interest in treating Barrett’s and has a reputation for performing these types of advanced endoscopic procedures.
Right now there is no heartburn or anti-reflux medication that has been proven to make Barrett’s esophagus completely disappear or decrease the risk of developing esophageal cancer. There is however, indirect evidence that decreasing the amount of reflux decreases the activity and potential for malignancy. For that reason, Barrett’s patients are always placed on lifelong antacid therapy with a strong antacid –proton pump inhibitor. These medications are also useful for managing the symptoms of discomfort associated with heartburn.
Certainly there are families in which more than one member has Barrett’s esophagus, or esophageal cancer, but there appear to be more factors involved than just genetics. There is one study that has shown that family members of people who have Barrett’s esophagus have more heartburn as compared to family members of people who do not have Barrett’s esophagus.
In families with a history of Barrett’s esophagus or esophageal cancer, it may be wise to have early screening of these conditions. Screening for Barrett’s esophagus should only be done by a fully trained, board certified, gastroenterologist.
Yes. You should follow the same diet that we recommend to patients who have heartburn without Barrett’s esophagus. You should follow a diet low in fat and stay away from foods that you know triggers your heartburn symptoms. Some examples of common heartburn triggers are tomato sauce, orange juice, and carbonated soda. Also, certain foods, such as chocolate and peppermint are also associated with heartburn. Keep evening meals small and try to avoid eating or drinking anything except water for several hours before bedtime. We also recommend five or more servings (cups) of fruits and vegetables daily. This diet may also be associated with a lower risk of developing some cancers, although this is unproven.
Absolutely not. Multiple studies of patients followed for many years, indicate that about 90-95% of patients who have Barrett’s esophagus DO NOT develop cancer. The risk of developing cancer in Barrett’s esophagus is low, estimated to be between 5%-10%. However, if you have Barrett’s you still have a more increased risk of esophageal cancer as compared to the general population. This is why we recommend periodic upper endoscopy with biopsy to check for cancer.
Yes – there are three major factors associated with esophageal cancer. One is the amount of Barrett’s epithelium (lining or protective surface of the esophagus) that is found during an endoscopy. Barrett’s is defined as short segment (less than 3 cm of abnormal tissue) and long segment (more than 3cm of abnormal tissue). Long segment Barrett’s generally has an increased risk of cancer in comparison with short segment Barrett’s.
Another factor is the presence of dysplasia. Dysplasia found during microscopic examination of the Barrett’s indicates areas of irregularity that raise the suspicion that a cancer might be developing. However, there are differing levels of dysplasia, ranging from indeterminate to high-grade. We begin to worry when we see the presence of intermediate or high-grade dysplasia.
Still another factor that raises our suspicion of esophageal cancer is obesity. Obese individuals with Barrett’s esophagus seem to have a higher risk of developing esophageal cancer. In fact, obesity seems to be the most important factor in causing heartburn, Barrett’s esophagus, and esophageal cancer. It is absolutely critical that you begin a comprehensive weight loss, diet and exercise program to help eliminate heartburn and its dangerous consequences.
If you have worries about your risk factors, talk with your doctor.
Patients who have esophageal cancer without metastases (spread of the cancer to other organs, such as the liver and lungs) are considered surgical candidates for an esophagectomy (surgical removal of the esophagus). Patients with a large cancer may be treated with endoscopic therapies that allow them to swallow more easily. Chemotherapy and radiation are also options, particularly for patients who are not good surgical candidates. We may recommend that some patients may be treated with chemotherapy and radiation therapy before esophagectomy to try and shrink the size of the tumor and improve patient survival.
If the cancer was detected early and the patient is not a good surgical candidate, ablation therapy may give the patient the best chance for a cure, but this approach is still considered experimental.
There are several strategies for the treatment of esophageal cancer. An experienced oncologist with a special interest in esophageal cancer is your best bet. Discuss this with your gastroenterologist, and do not be afraid of obtaining many opinions before deciding on which therapy sounds right to you.
In the case of Barrett’s esophagus with high grade dysplasia, physicians usually recommend surgery as the most likely therapy to prevent the development of a cancer. However, several academic centers are offering a less invasive approach in the treatment of high grade dysplasia Barrett’s. These centers usually recommend an endoscopic ultrasound test of the esophagus to look for any evidence of underlying cancer. They may also recommend endsopic mucosal resection in the esophagus to obtain deeper samples of the Barrett’s lining. If these tests are normal, the risk of cancer would appear to be much lower, and an endoscopic ablative therapy might be used to remove the Barrett’s tissue. Multiple centers in the U.S. and Europe are reporting very compelling data with these non-surgical techniques for treating high grade Barrett’s.
Barrett’s does raise your risk of esophageal cancer, but there is a lot you can do to lower that risk.
1. Follow your doctor’s advice and take your anti-acid daily.
2. Follow the dietary recommendations and lifestyle changes that will help reduce reflux.
3. Consider taking a daily aspirin, or other NSAID, if it doesn’t make your heartburn symptoms worse. You must have your doctor’s approval before beginning a daily NSAID to reduce cancer risk
4. Consider having your Barrett’s treated by one of the new non-surgical techniques.
5. Lose weight if you are obese -discuss safe dieting with your doctor
6. If you decide not to have your Barrett’s treated, be sure you are in a surveillance program that will monitor for signs of esophageal cancer
7. Take a daily vitamin and eat more fruits and vegetables