Barrett’s Esophagus

Barrett’s Esophagus is a disorder where the lining (mucosa) of the esophagus is replaced by tissue that is similar to the lining of the intestine. The process of this abnormal tissue transformation is called metaplasia and the disorder is often called Barrett’s Metaplasia (BM) or Intestinal Metaplasia (IM). The cause of BM is thought to be chronic regurgitation of gastric contents into the esophagus (Gastroesophageal Reflux Disease or GERD).  

Barrett’s is not a pre-cancer. It is, however, a risk factor for the development of esophageal cancer.  The incidence rate of esophageal adenocarcinoma in patients with BM is approximately 3 per 1000 person-years. The incidence of esophageal cancer has been rapidly increasing over the past several decades and Barrett’s is a major risk factor.  

Dysplasia is an abnormal proliferation of cells that is considered a precursor to cancer. The presence of dysplasia can be classified as low- or high-grade with high-grade dysplasia having a greater likelihood of progressing to cancer. Barrett’s is classified as either with (dysplastic) or without dysplasia (non-dysplastic). The risk of developing cancer increases to 8 per 1000 person-years in persons with low-grade dysplasia and to 50 per 1000 person-years in individuals with high-grade dysplasia. Persons with a long segment of Barrett’s (>3cm) are more likely to have dysplasia and are more likely to progress to esophageal cancer. The longer the segment of Barrett’s the greater the risk of cancer.

Treatment for Barrett’s Metaplasia involves aggressive treatment of gastroesophageal reflux disease. This may include a combination of various reflux medicines and diet and behavior changes. The primary treatment for Barrett’s esophagus is usually with proton pump inhibitors (PPIs, e.g. Priloses, Nexium, Prevacid, Protonix). These antacid medications offer the most effective protection against the progression of Barrett’s to esophageal cancer. Your doctor may also recommend that you take a daily baby aspirin to reduce cancer risk. Alginate therapy may also be used as an adjunct to treatment with PPIs. The alginate can form a protective coating on the esophagus and throat and help promote esophageal health. Surgical procedures to treat reflux are available for patients with severe GERD. The gold standard surgical treatment for GERD and Barrett’s esophagus is laparoscopic Nissen fundoplication with repair of a hiatal hernia if present. Fundoplication is a procedure whereas a part of the stomach is wrapped around the lower esophagus to augment (strengthen) the lower esophageal sphincter and help prevent reflux. Patients with Barrett’s require routine surveillance endoscopy and biopsy every 1-5 years depending on the presence of dysplasia and other risk factors for cancer development. The purpose of the surveillance endoscopy is to detect progression of the Barrett’s to dysplasia or early stage cancer that is readily treatable.  Esophageal cancer detected at a late stage is almost universally fatal. Patients with dysplasia require more frequent follow-up endoscopy than persons with non-dysplastic Barrett’s.Radiofrequency ablation (RFA) is an endoscopic procedure that is now available to eliminate Barrett’s esophagus and reduce the risk of developing esophageal cancer. The procedure takes approximately 30 minutes to complete and is performed as an outpatient. Numerous outpatient endoscopic RFA procedures may be required to eradicate the Barrett’s. RFA can reduce the risk of developing esophageal adenocarcinoma to 0.5 per 1000 person-years for persons with non-dysplastic BM, to 4.3 per 1000 person-years in persons with low-grade dysplasia and to 30 per 1000 person-years in high-grade dysplasia.