Barrett’s Esophagus and Esophageal Cancer: The dark side of the acid reflux epidemic

Barrett’s Esophagus and Esophageal Cancer: The dark side of the acid reflux epidemic

By Drew Schembre, MD, FASGE, FACG
Medical Director, Swedish Gastroenterology

Heartburn (which was once considered an annoying result of over-eating) has matured into a full-blown medical condition better known as gastro-esophageal reflux or GERD.

GERD, or the sensation of acid or other gastric fluids washing up into the chest or mouth, affects as many as 1 in 5 adults in the US on a monthly basis with up to 6% experiencing symptoms 2 or more times per week. Estimates suggest that about 5% of those who suffer from reflux will develop a potentially pre-malignant condition called Barrett’s esophagus (BE). Named after the British thoracic surgeon who erroneously suggested the condition resulted from a congenitally short esophagus, BE is characterized by “specialized intestinal lining” replacing normal squamous epithelium (ie, wet skin, like the lining of the mouth) in the lower esophagus in response to long-term, repetitive exposure to stomach acid.

While this may seem like a protective adaptation—Barrett’s tissue will not ulcerate and develop scarring the way squamous tissue does—it is inherently unstable and can progress to cancer. The risk for developing adenocarcinoma of the esophagus for people with BE is more than 30 times greater than for people without it.

Luckily, the absolute risk of progression from BE to cancer is relatively low. BE progresses to esophageal cancer at the rate of around 0.2% per year. Further, cancer doesn’t usually develop suddenly. Instead, it progresses through a series of stages termed “dysplasia” meaning bad or unfavorable changes that can be identified on biopsies collected at endoscopy. These changes progress from:

  • Barrett’s tissue without dysplasia. This condition does not usually warrant treatment but can be followed by endoscopy every 3-5 years.
  • Low-grade dysplasia. Subtle abnormalities become apparent but progression to cancer is still slow and infrequent. This stage can be treated or followed closely.
  • High-grade dysplasia. Here progression to cancer is much more common, occurring in 5-25% of individuals each year. Treatment is highly recommended.
  • Intra-mucosal cancer. Cancer cells remain confined to the most superficial layer of the esophagus and are at very low risk for metastasizing. This can sometimes be treated without surgery at an expert center.
  • Invasive cancer where cancer cells penetrate deeper layers of the esophagus and begin to spread to lymph nodes and distant sites. At this stage, superficial treatments offer little benefit and surgery and/or chemo and radiotherapy are usually necessary.

What are the symptoms of Barrett’s esophagus?

No specific symptoms indicate the presence of Barrett’s esophagus and up to 40% of people who have the condition don’t experience classic heartburn symptoms. The condition most commonly affects middle aged white men but can affect women and members of other ethnicities as well. Obesity, smoking and family history may increase the risk not only of developing Barrett’s esophagus but also likelihood of progression to cancer.

How is Barrett’s esophagus diagnosed?

No blood tests or x-rays (even CT or MRI scans) can detect Barrett’s. Endoscopy with biopsy remains the standard method for diagnosing Barrett’s and is recommended for individuals who suffer from frequent reflux symptoms (weekly or more often) that have persisted for several years. This is a low-risk test (much like a colonoscopy without the bowel prep) but does usually require sedation. Correctly identifying dysplasia can be tricky for many pathologists and may require review by an expert. If there is any question of high-grade dysplasia or early cancer on biopsies, the slides should be sent to a center of excellence for a second opinion.

What is surveillance strategy?

If a person has undergone endoscopy and this has not demonstrated Barrett’s esophagus it is extremely unlikely that it will develop after age 30. Once Barrett’s esophagus has been detected, most experts recommend repeat endoscopy with biopsies every 3-5 years in order to detect the development of dysplasia or cancer. If dysplasia is discovered, surveillance intervals need to be shortened or definitive treatment undertaken.

Comments
Brian E. Louie, MD
Tom, the answer to your question is a very long discussion. You should sit down with the physician who made the diagnosis and try to understand to what degree you have Barrett's. If you have symptoms of GERD then you should be treated. If you have not had PPI's I would start there. If you are on PPIs and still have symptoms, you may wish to consider surgery.
3/24/2014 9:07:21 AM
tom shanholtz
I recently found out I have barretts after having trouble trying to swallow. not sure what to do next?
3/23/2014 2:38:01 PM
Drew Schembre, MD, FASGE, FACG
Thanks for your questions - I would be happy to see you in our clinic, or you may wish to schedule a consultation directly with Dr. Louie for specific questions about the LINX procedure.
2/15/2013 4:49:53 PM
Flavia
Dr. Schembre, I just finished reading your colleague's blog on the Lynx procedure to treat GERD. I am a 40 year old female with a history of GERD since I was 16. My symptoms came and went for many years without treatment until I reached my early 30s and finally went to see a GI specialist who performed an endoscopy. The biopsy results showed short segment Barrett's Esophagus. He immediately put me on a PPI. I had headaches, it didn't relief my GERD symptoms and shortly after I became pregnant so I discontinued the use of it. My GERD was unbearable during the first trimester of pregnancy, but after that and all the way until I started weaning the baby from nursing, my stomach was perfect - no GERD whatsoever!- When the symptoms came back, which were and continue to be a dull pain or sensation of hunger in my LES at night between 4 and 6am, I went to get a second opinion at UNC and had a second endoscopy. This endoscopy showed Barrett's again of equivalent characteristics to the first endoscopy. The doctor put me on Nexium and did another endoscopy a year later. The Barrett's was gone! I have since stayed on the Nexium 40mg and have had 3 more endoscopies which have showed no Barrett's. My symptoms have been about 80% under control primarily due to the Nexium and my compliance to diet. However, the last endoscopy done a couple of months ago revealed a benign polyp in my stomach and the colonoscopy performed at the same time showed a polyp in my colon. The doctor didn't seem concerned about either one and explained to me that the prolonged use of any PPI can lead to these types of stomach polyps. I have been reading about the potential side effects of being on a PPI indefinitely, such as in my case, and some of them sound quite scary. I obviously take the Nexium so that I don't get the Barrett's back and risk ending up with esophageal cancer, but one of the scary side effects had to do with developing Atrophic Gastritis which preceeds stomach cancer. In your opinion, would I be a good candidate for a procedure like the Lynx, even though I know they haven't studied it in patients with BE? Do I help my self any with lowering the dose of Nexium to 20mg? Do I stay on it at the same dose and supplement my intake of folate, B12, calcium and iron to compensate for my Nexium induced malabsorbtion of these vitamins and minerals? Any light in this regard will be immensely appreciated! Thank you so much for your time!!
2/11/2013 10:23:26 PM
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