Barrett’s Esophagus

with Thomas Puetz, M.D., gastroenterologist, Advanced Healthcare

Last Updated: June 1, 2003

Heartburn and GERD (gastroesophageal reflux disease) cause discomfort, one that many people choose to treat with over-the-counter medications and lifestyle modifications. When these don’t work, some choose to tough it out. But, one of the side effects of GERD can be a permanent change in the tissue of the esophagus. This cellular change, called Barrett’s Esophagus, leads to an increased risk of developing a specific type of esophageal cancer called adenocarcinoma.

Reflux is a common disease, affecting greater than 20% of the U.S. population at some time or another. “Of these, about 6% to 12% will develop Barrett’s esophagus. That’s a large number of patients,” said Dr. Thomas Puetz, a gastroenterologist with Advanced Healthcare.

Only 0.5% per year of patients who have Barrett’s will develop esophageal cancer. However, the number of cases of adenocarcinoma is rising, and this type of cancer is difficult to treat.

There is no proven treatment for Barrett’s esophagus. However, people with Barrett’s need to be examined often and thoroughly to be certain that the abnormal cells are not becoming cancerous.

Symptoms
Patients who develop Barrett’s have no symptoms other than the ones normally found with reflux or GERD. If these symptoms diminish, it is not necessarily a good sign. “One of the key points about Barrett’s is that if symptoms improve it doesn’t mean the reflux is getting better. Often the change in tissue structure alleviates the obvious GERD symptoms,” Dr. Puetz said.

Who is at risk
Those who suffer from GERD are at risk for Barrett’s. It is most common in Caucasian males greater than 40 years of age. Risks include: Having reflux at an early age, experiencing symptoms over a longer period of time and having increased nighttime reflux. This leads researchers to believe that a long exposure to stomach acid triggers the change in tissue structure.

Screening for Barrett’s
Because it is impossible to tell which patients will develop Barrett’s, medical guidelines recommend that doctors should screen for Barrett’s in patients over 50 years of age who have experienced reflux for more than five years.

After Barrett’s is diagnosed, the problem becomes how often to perform surveillance exams. This depends on the state of the tissues found on the initial biopsies. “If I identify a patient with low-grade dysplasia (mild abnormal appearing cells), I would do biopsies every six months to a year. With high-grade dysplasia (severe abnormal appearing cells), there is a ten to twenty percent chance of cancer already being present in the esophagus. Then, it is better to look at surgery or alternate forms of monitoring,” the doctor added.

The standard procedure for screening is an endoscopic examination of the esophagus. For this, a patient is mildly sedated and a thin tube is guided down the back of the throat into the esophagus (swallowing tube). A video camera allows gastroenterologists to view the esophagus and to obtain tissue samples. “Taking samples is very important since fifty percent of Barrett’s will be missed if only relying on visual changes,” Dr. Puetz said.

Treatment of Barrett’s
Unfortunately, once the structure of the cells in the esophagus has changed, there is little physicians or patients can do to reverse this. However, aggressive and ongoing treatment for GERD seems to slow the growth of the abnormal tissue. Studies to date have not shown a decrease in the risk of developing esophageal adenocarcinoma.

Future testing methods
Because sedation is required for screening examinations, it must be done in a surgical center or hospital. However, in the near future, ultra-thin endoscopes will be available that will use the nasal passage to enter the esophagus, thereby eliminating the need for sedation. This should decrease the cost of screening and improve safety.

In addition, research is being performed to identify genetic changes that predispose a patient to developing cancer. If a genetic link can be found, physicians will have another means of knowing which patients should be screened more aggressively.

Increasing success
While Barrett’s esophagus is not a new condition, the recommended screening and surveillance programs are so recent that ongoing studies will need to be completed to delineate the long-term benefits of these guidelines. “At this time I believe that the potential benefit of identifying patient’s at risk for this deadly cancer is certainly worthwhile,” Dr. Puetz concluded.

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