Barrett's Oesophagus

What is Barrett's oesophagus?

The oesophagus is the muscular tube that carries food from the mouth to the stomach. Barrett's oesophagus occurs as a complication of chronic gastro-oesophageal reflux disease (GORD). In Barrett's oesophagus, there are changes in the cells on the inner lining of the oesophagus at the lower end. GORD refers to the reflux of acidic fluid from the stomach into the oesophagus, and is classically associated with heartburn. The condition is named after a thoracic surgeon, Norman Barrett, who described the condition in 1950.

Barrett’s oesophagus can occur at any age. It can affect both men and women, but it is more common in men.

Why does it occur?

The stomach produces acid to help digest food. In addition the stomach fluid may contain bile acids (in bile produced by the liver) and enzymes (produced by the pancreas) that have refluxed back from the duodenum to the stomach (the duodenum is the first part of the small intestine beyond the stomach).

The stomach is lined by tissue that is resistant to acid, but the oesophagus isn't. In some people, the acid can inflame and irritate the oesophagus, causing pain and heartburn. This is often referred to as gastro-oesophageal reflux disease (GORD) or reflux oesophagitis. The change of the normal lining of the oesophagus into Barrett’s oesophagus is thought to be caused by exposure to acid and perhaps bile during times of reflux. There is some evidence that the bile and pancreatic enzymes combined with the acid may be more injurious than the acid alone. Approximately 10% of individuals with GORD develop Barrett's oesophagus.

Barrett's oesophagus may run in some families.

Why Barrett's oesophagus is a concern?

Barrett's oesophagus is not a cancer. However, over time the cells can develop into something called dysplasia.

Dysplasia

Dysplasia can be either low-grade or high-grade. In low-grade dysplasia, the cells are slightly abnormal. In high-grade, the cells are more abnormal and can represent a early cancer. This risk is small but definite and found to be around 1 in every 200 patients with Barrett’s every year. About 3 in every 100 people (3%) who have Barrett's oesophagus will develop oesophageal cancer during their lifetime. The connection between adenocarcinoma of the oesophagus and Barrett's oesophagus is now clear. In fact this type of tumour is increasing in frequency in most countries.

What are the symptoms of Barrett's oesophagus?

Barrett's oesophagus has no unique symptoms. Patients with Barrett's have the symptoms of GORD - such as heartburn, regurgitation of fluid/food and nausea. The general trend is for Barrett's patients to have more severe GORD. However not all patients with Barrett's have marked symptoms of GORD, and some patients are detected almost accidentally with minimal symptoms of GORD.

Heartburn is a burning sensation behind the breastbone, usually in the lower half, but which may extend all the way up to the throat. Sometimes it is accompanied by burning or pain in the pit of the stomach just below where the breastbone ends. The second most common symptom is regurgitation (bringing back up) of bitter tasting fluid or food. GORD symptoms are often worse after meals and when lying flat.

The refluxed, regurgitated fluid may involve the lungs or voice box (larynx) and thereby produce what is called the extra-oesophageal (outside the oesophagus) symptoms of GORD. These symptoms include new onset adult asthma, frequent bronchitis, chronic cough, sore throats, and hoarseness. For reasons not understood some GORD patients have minimal heartburn but experience other GORD symptoms - such as regurgitation of bitter tasting fluid/food or even the extra-oesophageal symptoms - that are more dominant in either frequency and/or severity.

Other clinical features of GORD are due to strictures and ulceration of the oesophagus. A stricture is a scarring (fibrosis) of the oesophagus that may cause difficulty swallowing (dysphagia). The dysphagia is sensed as a sticking (stopping) in the chest (actually in the oesophagus) of solid food, or even liquids when the dysphagia is severe. Strictures must be treated by stretching them during endoscopy with dilators. Untreated, strictures may promote more spillage of food and/or gastric fluids into the lungs. Not commonly seen in GORD is massive gastrointestinal (GI) bleeding that is caused by inflammation of the oesophagus. Such massive GI bleeding would result in vomiting blood or passing black or maroon stools.

However more commonly an inflamed oesophagus can cause slow bleeding that is detected when anaemia (low blood count) is found and/or stools are tested chemically for blood.

How its diagnosed?

The diagnosis of Barrett's oesophagus rests upon seeing (at an endoscopy) a pink oesophageal lining (mucosa) that extends a short distance up the oesophagus from the gastro-oesophageal junction and finding columnar cells on biopsy of the lining. Therefore, to make a diagnosis of Barrett’s oesophagus an upper GI endoscopy of the oesophagus must be done.

How its treated?

Surveillance

Often, people with Barrett's oesophagus are advised to have their condition monitored. This means checking at regular intervals for any further changes in the cells. It is known as surveillance and usually involves regular endoscopies and biopsies.

You may have endoscopies at intervals ranging from every three months to every three years. This will depend on whether your condition is changing and the degree of change.

Reducing acid reflux

The treatment for Barrett's oesophagus is in general essentially the same as for GORD. However treatment of GORD either medically (acid-suppression medication) or surgically (e.g. fundoplication) does not result in the disappearance of Barrett's oesophagus or in a reduced cancer risk.

Removing the affected area

Dysplasia is a cellular process that occurs in the Barrett's mucosal lining of the oesophagus and indicates a heightened risk of cancer. Periodic endoscopic oesophageal biopsies are done in Barrett's to look for the dysplasia.

If a biopsy shows that there are continuing changes in the cells which may progress to cancer, your surgeon may suggest treatment to remove the affected area. This can be done in different ways. These include radiofrequency ablation (RFA), Argon plasma coagulation (APC), endoscopic mucosal resection (EMR), and surgical resection (Oesophagectomy).

Argon plasma coagulation (APC)

APC uses electrical energy in the form of plasma (ionised gas) to burn and destroy abnormal cells. Using an endoscope, a probe is used to give an electrical current and argon gas to the abnormal area. The electrical current creates an ionisation in the argon gas causing a high energy plasma with will burn only a small thickness on the inner layer of the oesophagus which is adequate to burn the abnormal cell layer without causing deeper burns. This treatment is usually done under sedation. This has to be repeated several times to achieve complete ablation with 8-12 weeks interval.

Radiofrequency ablation (RFA)

RFA uses heat to destroy abnormal cells. Using an endoscope, a probe called an electrode is used to give an electrical current (radiofrequency) to the abnormal area. The electrical current heats the abnormal cells to a high temperature, which destroys (ablates) them. This treatment is usually done under sedation. Unfortunately RFA is not yet available in Sri Lanka.

Endoscopic mucosal resection (EMR)

This is indicated for Barrett’s if they develop dysplasia. The aim of EMR is to remove the dysplastic area of the oesophagus lining, without damaging the rest of the oesophagus. The affected area is removed using a thin wire called a snare. The snare is put through an endoscope. EMR can be done as a day case under sedation, but you may need to stay in hospital overnight.

Surgical resection

Sometimes more extensive surgery is needed. The surgeon will remove the section of the oesophagus that contains the abnormal cells (Oesophagectomy). The stomach is then joined to the remaining part of the oesophagus. This is a major surgery with high morbidity and mortality.