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BARRETT'S ESOPHAGUS OVERVIEW — The esophagus is the tube that connects the mouth with the stomach (figure 1). Barrett's esophagus occurs when the normal cells that line the lower part of the esophagus (called squamous cells) are replaced by a different cell type (called intestinal cells). This process usually occurs as a result of repetitive damage to the inside of the esophagus caused by longstanding gastroesophageal reflux disease (GERD). In people with GERD, the esophagus is repeatedly exposed to excessive amounts of stomach acid and bile. Interestingly, the intestinal cells of Barrett's esophagus are more resistant to acid and bile than squamous cells, suggesting that these cells may develop to protect the esophagus from acid exposure. The problem is that the intestinal cells have a risk of transforming into cancer cells.
More detailed information about Barrett's esophagus is available separately. (See "Barrett's esophagus: Epidemiology, clinical manifestations, and diagnosis" and "Barrett's esophagus: Surveillance and management".)
BARRETT'S ESOPHAGUS RISK FACTORS — There are a number of factors that increase the risk of developing Barrett's esophagus:
Age — Barrett's esophagus is most commonly diagnosed in middle-aged and older adults; the average age at diagnosis is approximately 55 years. Children can develop Barrett's esophagus, but rarely before the age of five years.
Gender — Men are more commonly diagnosed with Barrett's esophagus than women.
Ethnic background — Barrett's esophagus is most common in White populations, less common in Hispanic populations, and uncommon in Asian and Black populations.
Obesity — Barrett's esophagus is especially associated with the central type of obesity in which fat accumulates predominantly in the abdomen.
Lifestyle — Smokers are more commonly diagnosed with Barrett's esophagus than nonsmokers.
Family history — A history of Barrett's esophagus or adenocarcinoma of the esophagus in a first-degree relative increases one's risk of having Barrett's esophagus.
BARRETT'S ESOPHAGUS SYMPTOMS — Barrett's esophagus itself produces no symptoms. Patients may have symptoms of underlying GERD, including heartburn, regurgitation of stomach contents, and, less commonly, difficulty swallowing.
BARRETT'S ESOPHAGUS DIAGNOSIS — A health care provider may suspect Barrett's esophagus based upon a person's symptoms and the risk factors described above. An endoscopy is needed to confirm the abnormal esophageal lining.
Upper endoscopy — Upper endoscopy is a test that allows your doctor to see the inside of the esophagus and stomach. Before the test, you are sedated to prevent discomfort. The doctor will insert a thin lighted tube into the esophagus. The tube has a camera, which allows the doctor to see the lining of the esophagus.
Normally, the lining should appear pale and glossy; in a person with Barrett's esophagus, the lining appears pink or red and velvety. If the endoscopic appearance suggests Barrett's esophagus, the doctor will remove a small sample of the lining (a biopsy) during the endoscopy so that it can be examined with a microscope for signs of Barrett's. (See "Patient education: Upper endoscopy (Beyond the Basics)".)
Endoscopy detects most (>80 percent) but not all cases of Barrett's esophagus. Individual variations in the anatomy of the esophagus and the area where it meets the stomach can make the diagnosis of Barrett's esophagus difficult in some people.
BARRETT'S ESOPHAGUS TREATMENT — The goals of treatment in patients with Barrett's esophagus are to control reflux symptoms and to prevent the Barrett's from turning into cancer. Aggressive reflux treatment may be more effective in preventing cancer than treating only when there are reflux symptoms. (See "Barrett's esophagus: Surveillance and management".)
Behavior and diet changes — The first priority in treating Barrett's esophagus is to stop the damage to the esophageal lining, which usually means eliminating acid reflux. Most patients are advised to avoid certain foods and behaviors that increase the risk of reflux. Foods that can worsen reflux include:
●Chocolate
●Coffee and tea
●Peppermint
●Alcohol
●Fatty foods
Acidic juices such as orange or tomato juice may also worsen symptoms. Carbonated beverages can be a problem for some people. (See "Patient education: Gastroesophageal reflux disease in adults (Beyond the Basics)".)
Behaviors that can worsen reflux include eating meals just before going to bed, lying down soon after eating meals, and eating very large meals. Placing bricks or blocks under the head of the bed (to raise it by about six inches) can help to keep acid in the stomach while sleeping. It is not helpful to use additional pillows under the head.
Medications — A clinician may prescribe medications that reduce the amount of acid produced by the stomach. A class of medications called proton pump inhibitors is commonly recommended. Six different formulations (some of which are available as a generic) are currently available: omeprazole (Prilosec), esomeprazole (Nexium), lansoprazole (Prevacid), dexlansoprazole (Dexilant), rabeprazole (Aciphex) and pantoprazole (Protonix); any of these is an acceptable option.
Surgery — Some people with GERD may benefit from surgical procedures to reduce reflux. Surgery is not the best treatment in all situations, so you should discuss this option with your doctor. More information about surgical treatments for reflux is available in a separate topic review. (See "Patient education: Gastroesophageal reflux disease in adults (Beyond the Basics)".)
BARRETT'S ESOPHAGUS COMPLICATIONS — One potential complication of Barrett's esophagus is that, over time, the abnormal esophageal lining can develop early precancerous changes. The early changes may progress to advanced precancerous changes, and finally to frank esophageal cancer. If undetected, this cancer can spread and invade surrounding tissues.
However, progression to cancer is uncommon for any individual patient; studies that follow patients with Barrett's esophagus reveal that fewer than 0.5 percent of patients develop esophageal cancer per year. Furthermore, patients with Barrett's esophagus appear to live approximately as long as people who are free of this condition. Patients often die of other causes before Barrett's esophagus progresses to cancer.
BARRETT'S ESOPHAGUS MONITORING — Monitoring for precancerous changes is recommended for most patients with Barrett's esophagus. At this time, monitoring includes periodic endoscopy with tissue biopsy. (See "Patient education: Upper endoscopy (Beyond the Basics)".)
Although new technologies for monitoring are on the horizon, most are still considered to be experimental. Experts do not agree about the usefulness of monitoring. The benefits of monitoring depend upon each person's chance of developing esophageal cancer, which may be difficult to determine.
Benefits — Reasons to perform endoscopic monitoring include:
●Monitoring can detect curable, precancerous changes (dysplasia) in the esophageal lining. These changes may indicate that the person has an increased risk of cancer. Early detection may be especially important for younger patients. Precancerous changes in Barrett's esophagus usually are treated with endoscopic procedures, rather than with the surgery, radiation and chemotherapy needed to treat invasive cancers. (See 'Endoscopic eradication therapy' below.)
●Monitoring may detect cancer at an earlier stage, when it can be more effectively treated.
Limitations — However, not all patients will benefit from endoscopic monitoring.
●Progression of Barrett's esophagus to cancer is uncommon.
●Endoscopy carries certain risks and often causes anxiety.
●Endoscopy may miss areas with premalignant changes or cancer.
●Even if endoscopy detects a cancer, the available treatment options may have unacceptably high risks.
●There is no proof that endoscopic monitoring prolongs life or prevents death from cancer of the esophagus.
PRECANCEROUS CHANGES AND BARRETT'S ESOPHAGUS
Confirmation and staging — If precancerous changes are discovered, they should be confirmed by a second pathologist, an expert in examining tissue samples. It is sometimes difficult to correctly identify precancerous changes, especially when there is inflammation (usually caused by the ongoing reflux of acid). Many clinicians increase the dose of acid-suppressing medications in this situation.
The precancerous changes must then be graded as "low-grade dysplasia", "high-grade dysplasia," or "intramucosal carcinoma" depending upon their severity.
Treatment options — The management of low-grade dysplasia is controversial. Some physicians recommend frequent endoscopic surveillance for patients with low-grade dysplasia, while others recommend destroying the abnormal tissue with endoscopic eradication therapy (see below). Either option is acceptable, but recent studies suggest that endoscopic eradication therapy might be preferable.
Endoscopic eradication therapy generally is recommended for the treatment of high-grade dysplasia or intramucosal carcinoma in Barrett's esophagus.
Endoscopic eradication therapy — Endoscopic eradication therapy can be used to treat all grades of dysplasia in Barrett's esophagus. Endoscopic eradication therapy usually involves a combination of endoscopic mucosal resection to remove any worrisome areas identified by the endoscopists and endoscopic ablation of the remaining Barrett's esophagus, usually with radiofrequency ablation.
Endoscopic mucosal resection — Endoscopic mucosal resection (EMR) involves the removal of a large but thin area of esophageal tissue through an endoscope. EMR provides large tissue specimens that can be examined by the pathologist to determine the character and extent of the abnormality and determine if an adequate amount of tissue was removed. Therefore, it can help to confirm the person's diagnosis and can completely treat the abnormality (if the abnormal tissue is removed completely). However, this technique is generally performed only in specialized centers. Typically, EMR is performed if the endoscopist sees a worrisome area of nodularity in the Barrett's esophagus. EMR is commonly followed by ablation of the remaining Barrett's esophagus, usually with radiofrequency ablation. (See 'Radiofrequency ablation' below.)
Radiofrequency ablation — Radiofrequency ablation (RFA) is an endoscopic procedure that uses radiofrequency energy (microwaves) to destroy the Barrett's cells. In short-term studies, RFA has been shown to prevent high-grade dysplasia from progressing to cancer and to prevent low-grade dysplasia from developing more advanced features. However, there is limited information on the long-term outcome of this approach. In approximately 5 percent of patients, the procedure causes a complication, such as narrowing of the esophagus, which may require repeated treatments to open the esophagus.
Another concern with RFA is that, in a small minority of patients with high-grade dysplasia or intramucosal carcinoma (less than 2 percent), there may be cancer in the lymph nodes adjacent to the esophagus. RFA cannot cure cancer in the lymph nodes. In all cases, the patient and family should discuss the risks and benefits of possible treatments with a health care provider.
Finally, Barrett's esophagus can recur even after it has been completely eradicated by RFA. Therefore, RFA does not eliminate the need for endoscopic monitoring.
SUMMARY — Despite the uncertainties surrounding the monitoring and treatment of Barrett's esophagus, there is consensus on one matter: The available options should be tailored to the individual patient. The following are general guidelines:
●People with Barrett's esophagus should be treated with a proton pump inhibitor. This may improve or eliminate symptoms of heartburn, reduce inflammation, help prevent complications, and improve the accuracy of endoscopy evaluation.
●People without evidence of precancerous changes (ie, no dysplasia) or esophageal cancer should have endoscopy performed every three to five years to look for the development of precancerous changes, unless there are other medical conditions that increase the small risks usually associated with endoscopy.
●If endoscopy reveals a precancerous change (dysplasia), this finding should be confirmed by at least one expert; if necessary, additional tissue samples should be collected to resolve any doubt.
●People with early precancerous changes (low-grade dysplasia) often are treated with endoscopic eradication therapy. Another acceptable option is to have repeat endoscopy at 6 and 12 months, followed by annual endoscopy if the lesion does not appear to progress.
●People with confirmed, advanced precancerous changes (high-grade dysplasia or intramucosal carcinoma) should have endoscopic eradication therapy.
WHERE TO GET MORE INFORMATION — Your health care provider is the best source of information for questions and concerns related to your medical problem.
This article will be updated as needed on our website (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below.
Patient level information — UpToDate offers two types of patient education materials.
The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Patient education: Acid reflux and gastroesophageal reflux disease in adults (The Basics)
Patient education: Esophagitis (The Basics)
Patient education: Barrett's esophagus (The Basics)
Patient education: Esophageal cancer (The Basics)
Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.
Patient education: Upper endoscopy (Beyond the Basics)
Patient education: Gastroesophageal reflux disease in adults (Beyond the Basics)
Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.
Barrett's esophagus: Treatment of high-grade dysplasia or early cancer with endoscopic resection
Barrett's esophagus: Epidemiology, clinical manifestations, and diagnosis
Barrett's esophagus: Surveillance and management
Barrett's esophagus: Evaluation with optical chromoscopy
Barrett's esophagus: Pathogenesis and malignant transformation
Barrett's esophagus: Treatment with radiofrequency ablation
The following organizations also provide reliable health information.
●National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
●American Gastroenterological Society
●American College of Gastroenterology
●American Society for Gastrointestinal Endoscopy
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