Barrett's Esophagus

Barrett's Esophagus - What is Barrett's Esophagus?

Barrett's esophagus (oesophagus) (sometimes called Barrett's syndrome, CELLO, columnar epithelium lined lower esophagus and colloquially referred to as Barrett's) refers to an abnormal change (metaplasia) in the cells of the lower end of the esophagus thought to be caused by damage from chronic acid exposure, or reflux esophagitis.

The normal lining of the esophagus (squamous epithelium) is replaced by an intestinal-type lining (columnar epithelium). This replacement, however, is more cosmetic than substantive, because genetic analyses and kinome profiles indicate that the changed cells, which phenotypically appear to be columnar epithelium, actually retain important aspects of squamous epithelium on a molecular level.

Barrett's esophagus is found in 5-15% of patients who seek medical care for heartburn (gastroesophageal reflux disease, GERD), although a large subgroup of patients with Barrett's esophagus do not have symptoms.

Diagnosis of Barrett's esophagus requires endoscopy (more specifically, esophagogastroduodenoscopy, a procedure in which a small tube with a camera at the top is used to look at the esophagus, stomach and first part of the bowels) and biopsy (taking small tissue samples which are analysed using microscopy).

The progression from Barrett's esophagus to esophageal cancer is divided into non-dysplastic changes, low-grade and high-grade dysplasia (abnormal cell maturation associated with a risk of progression to cancer) and frank carcinoma.

In high-grade dysplasia, the risk of developing cancer might be at 10% per patient-year or greater.

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Barrett's Esophagus Symptoms

Barrett's esophagus is caused by gastro-oesophageal reflux disease which allows the stomach's contents to damage the cells lining the lower esophagus.

Researchers are unable to predict which heartburn sufferers will develop Barrett's esophagus. While there is no relationship between the severity of heartburn and the development of Barrett's esophagus, there is a relationship between chronic heartburn and the development of Barrett's esophagus.

Sometimes people with Barrett's esophagus will have no heartburn symptoms at all. In rare cases, damage to the esophagus may be caused by swallowing a corrosive substance such as lye.

The change from normal to premalignant cells that indicates Barrett's esophagus does not cause any particular symptoms. However, warning signs that should not be ignored include:

  • frequent and longstanding heartburn
  • trouble swallowing (dysphagia)
  • vomiting blood
  • pain under the breastbone where the esophagus meets the stomach
  • unintentional weight loss because eating is painful

This article is licensed under the Creative Commons Attribution-ShareAlike License. It uses material from the Wikipedia article on "Barrett's esophagus" All material adapted used from Wikipedia is available under the terms of the Creative Commons Attribution-ShareAlike License. Wikipedia® itself is a registered trademark of the Wikimedia Foundation, Inc.

Barrett's Esophagus Pathology

Barrett's esophagus is marked by the presence of columnar epithelia in the lower esophagus, replacing the normal squamous cell epithelium—an example of metaplasia.

The secretory columnar epithelium may be more able to withstand the erosive action of the gastric secretions; however, this metaplasia confers an increased risk of adenocarcinoma.

The metaplastic columnar cells may be of two types: gastric (similar to those in the stomach, which is NOT technically Barrett's esophagus) or colonic (similar to cells in the intestines).

A biopsy of the affected area will often contain a mixture of the two. Colonic-type metaplasia is the type of metaplasia associated with risk of malignancy in genetically susceptible people.

The metaplasia of Barrett's esophagus is grossly visible through a gastroscope, but biopsy specimens must be examined under a microscope to determine whether cells are gastric or colonic in nature.

Colonic metaplasia is usually identified by finding goblet cells in the epithelium and is necessary for the true diagnosis of Barrett's.

There are many histologic mimics of Barrett's esophagus (i.e. goblet cells occurring in the transitional epithelium of normal esophageal submucosal gland ducts, "pseudogoblet cells" in which abundant foveolar (gastric) type mucin simulates the acid mucin true goblet cells).

Assessment of relationship to submucosal glands and transitional-type epithelium with examination of multiple levels through the tissue may allow the pathologist to reliably distinguish between goblet cells of submucosal gland ducts and true Barrett's esophagus (specialized columnar metaplasia).

Use of the histochemical stain Alcian blue pH 2.5 is also frequently used to distinguish true intestinal-type mucins from their histologic mimics.

Recently, immunohistochemical analysis with antibodies to CDX-2 (specific for mid and hindgut intestinal derivation) has also been utilized to identify true intestinal-type metaplastic cells.

It has been shown that the protein AGR2 is elevated in Barrett's esophagus, and can be used as a biomarker for distinguishing Barrett's epithelium from normal esophageal epithelium.

After the initial diagnosis of Barrett's esophagus is rendered, affected persons undergo annual surveillance to detect changes that indicate higher risk to progression to cancer: development of dysplasia.

There is considerable variability in assessment for dysplasia among pathologists.

Recently, gastroenterology and GI pathology societies have recommended that any diagnosis of high grade dysplasia in Barrett's be confirmed by at least two fellowship trained GI pathologists prior to definitive treatment for patients.

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Barrett's Esophagus Treatments

The risk of malignancy is highest in the U.S. in Caucasian men > 50 years of age with > 5 years of symptoms. It is unusual for African-American men to develop adenocarcinoma of the esophagus, the cancer associated with Barrett's.

Current recommendations include routine endoscopy and biopsy (looking for dysplastic changes). If two endoscopies and biopsy sessions performed within 12 months are negative for dysplasia then surveillance can be performed every 3 years while the underlying reflux is controlled with proton pump inhibitor drugs in combination with measures to prevent reflux.

For patients found to have low grade or high grade dysplasia close observation and repeat endoscopy and biopsies are indicated and the patient should be followed closely by a gastroenterologist.

Proton pump inhibitor drugs have not yet been proven to prevent esophageal cancer. Laser treatment is used in severe dysplasia, while overt malignancy may require surgery, radiation therapy, or systemic chemotherapy.

Additionally, a recent 5-year random-controlled trial has shown that photodynamic therapy using photofrin is statistically more effective in eliminating dysplastic growth areas than sole use of a proton pump inhibitor.

There is presently no reliable way to determine which patients with Barrett's esophagus will go on to develop esophageal cancer, although a recent study found that the detection of three different genetic abnormalities were associated with as much as a 79% chance of developing cancer in 6 years.

Endoscopic mucosal resection (EMR) has also been evaluated as a management technique.

Additionally an operation known as a Nissen fundoplication can reduce the reflux of acid from the stomach into the esophagus.

In a variety of studies, non-steroidal anti-inflammatory drugs (NSAIDS), like aspirin, have shown evidence of preventing esophageal cancer in Barrett's esophagus patients.

However, none of these studies have been randomized, placebo controlled trials, which are considered the gold standard for evaluating a medical intervention. In addition, the best dose of NSAIDs for cancer prevention is not yet known.

This article is licensed under the Creative Commons Attribution-ShareAlike License. It uses material from the Wikipedia article on "Barrett's esophagus" All material adapted used from Wikipedia is available under the terms of the Creative Commons Attribution-ShareAlike License. Wikipedia® itself is a registered trademark of the Wikimedia Foundation, Inc.