Barrett’s Esophagus

Millions of Americans feel acid reflux in some way, shape or form. Newsday columnist Saul Friedman was one of them, and he, like many others, turned to antacids to soften the burn. The apparent solution, however, might have been the problem as symptoms of a far more serious issue — cancer — were masked by the antacids and Barrett’s esophagus.

Barrett’s esophagus is a known risk factor for esophageal cancer, and discovering it early can help physicians keep a lookout for cancer development. But Barrett’s esophagus is difficult to diagnose, and many patients don’t know they have it until they discover they have cancer.

This is the catch-22 of Barrett’s esophagus. Friedman, in the Feb. 9 edition of his "Gray Matters" column in Newsday, described how a combination of his Barrett’s esophagus and use of antacids to alleviate his heartburn symptoms actually masked the symptoms of his cancer. He eventually underwent radiation and chemotherapy treatment, and ultimately lost his esophagus to surgery.

What is Barrett’s Esophagus?

On its way to the stomach, the esophagus passes through a hole in the diaphragm where it joins with the stomach, which is located completely below the diaphragm. This area where the esophagus and stomach meet is called the squamocolumnar junction.

The lining of a normal esophagus consists of a pinkish-white tissue known as squamous epithelium. The stomach, on the other hand, is lined by normal columnar lining, or red stomach tissue. Oftentimes, the bottom part of the esophagus is lined with normal columnar epithelium. Barrett’s esophagus arises when the esophagus’ normal lining has been replaced by an abnormal red columnar epithelium. This material is red like normal stomach tissue, but a closer look under a microscope reveals other than normal stomach tissue.

A British surgeon named Norman Barrett first described the condition in 1950. He initially theorized that the red-colored lining afflicting patients’ esophagi was actually part of the stomach and that they were likely born with a short esophagus. Later, the definition of Barrett’s esophagus evolved to say that the condition existed when any red esophageal lining, including normal stomach lining, was greater that 3 cm in length. Today, the American College of Gastroenterology says Barrett’s esophagus is "a change in the esophageal epithelium (lining) of any length that can be recognized at upper endoscopy and is confirmed to have intestinal metaplasia at biopsy."

In simple terms, Barrett’s esophagus, which affects approximately 3.3 million Americans, occurs when the normal lining of the esophagus changes and is replaced by a tissue similar to what is normally seen in the stomach.

What Causes It?

What causes Barrett’s esophagus? It’s simply the consequence of years of chronic heartburn, or gastroesophageal reflux disease (GERD). Stomach acid and bile that backwash into the esophagus can injure the esophagus’ normal lining. And in approximately 10 percent of people who have severe GERD for many years, the normal esophageal lining does not grow back and is instead replaced by the tougher abnormal lining, which marks Barrett’s esophagus.

Researchers don’t know why the esophagus’ lining transforms in reaction to the acid backwash. Ironically, this transformation might help resist the discomfort of acid reflux better than the normal lining because the abnormal lining is tougher. The risk of this, however, is that patients can be unaware of the development of cancer. Barrett’s esophagus is a risk factor for esophageal adenocarcinoma, or cancer associated with Barrett’s esophagus.

This masked warning sign for cancer was also shown in a recent Swedish study in which 44 percent of patients with Barrett’s esophagus didn’t have heartburn symptoms in the last three months of observation. Furthermore, 40 percent of patients diagnosed with esophageal adenocarcinoma say they never had the typical chest burning or acid reflux associated with GERD.

Cancer Risk

Barrett’s esophagus is not in itself symptomatic and is only important to diagnose because it seems to precede esophageal adenocarcinoma. The risk of developing this particular type of cancer is 30 to 125 times higher in those with Barrett’s esophagus than those who do not have the condition. However, even for those with Barrett’s esophagus, the risk of developing cancer is still small: between 0.4 percent and 0.5 percent per year. The cancer is often not curable, though, partly due to the fact that the disease is often discovered at its late stages when treatments are not as effective.

The U.S. Department of Health and Human Services (HHS) recommends periodic endoscopic exams to look for early warning signs of cancer for those with Barrett’s esophagus. When these people do develop cancer, the process seems to go through an intermediate stage in which the cancer cells appear on the Barrett’s tissue. This condition is called dysplasia and can only be seen in biopsies under a microscope.

Approximately 15,000 Americans will be diagnosed each year with cancer in the esophagus, and 14,000 will die. Cancer in the esophagus was long seen on the normal squamous cells, largely due to smoking and drinking alcohol. But adenocarcinoma has been on the rise in recent years in the United States. In fact, a recent study presented at the 2008 Gastrointestinal Cancers Symposium found that adenocarcinoma affected three times more people in 2002 than in 1986. And in the study, researchers found a correlation between the rising numbers of adenocarcinoma and the rise of obesity in the United States.

Risk Factors

Barrett’s esophagus is more likely to develop in older people, with an average diagnosis age of around 60. A typical Barrett’s esophagus patient is a middle-aged or elderly white man with a history of heartburn, but anyone can develop the condition. Men are four times as likely as women to develop the condition, and they are eight times as likely as women to develop cancer associated with Barrett’s esophagus.

Obesity is seen as a strong risk factor for esophageal adenocarcinoma as well as a risk factor for Barrett’s esophagus. A recent study of male patients at a Veteran’s Administration hospital found overweight patients had a 2.5-times increased risk of developing Barrett’s esophagus compared to normal weight patients. No one knows exactly why obesity increases the risk, but one theory suggests that the fat in the abdominal area places pressure on the stomach — especially when lying down — and increases the acid reflux that leads to heartburn.

Symptoms and Diagnosis

Heartburn is typically a precursor for Barrett’s esophagus, but there are no specific heartburn symptoms that can help diagnose the condition. Typical GERD symptoms include a burning sensation in the chest or upper abdomen due to meals or body position, or acid regurgitation into the esophagus or mouth. Because of the cancer risk associated with Barrett’s esophagus, one should also look out for the following warning signs of severe GERD or esophageal cancer: bloody, red or black bowel movements, vomiting blood or material that resembles coffee grounds, food stuck in the esophagus, anemia or unexplained weight loss.

A procedure known as esophagogastroduodenoscopy (EGD or upper endoscopy) with a biopsy is currently the only way that Barrett’s esophagus can be diagnosed. During this treatment, a gastroenterologist will examine the esophagus, stomach and the duodenum.

Unfortunately, a large majority of patients with Barrett’s esophagus never see their doctor when heartburn symptoms arise, and, as a result, many patients who develop cancer in their esophagus never knew they had a major risk factor for developing cancer.

According to the HHS, there currently are no accepted guidelines on who should have an endoscopy to check for Barrett’s esophagus. Part of the reason for this, according to the federal agency, is that the screenings are expensive and patients are placed at a risk of side effects. In addition, the probability of finding Barrett’s esophagus is low and finding the condition has not been proven to prevent cancer deaths. However, HHS said many physicians recommend adults over the age of 40 and who have had GERD symptoms for years should have endoscopy performed to see whether Barrett’s esophagus is present.

Treatment

Other than completely removing the affected sections of the esophagus, there is no cure for Barrett’s esophagus. But as with many medical conditions, lifestyle changes can alter the course of a problem. Making certain changes can decrease the chances of acid reflux and help avoid the use of medication.

Specifically, foods that cause heartburn symptoms — such as chocolate, citrus and tomatoes — should be avoided. No food or drink (except water) should be consumed three hours before bedtime. A low-fat diet can also help empty the stomach’s contents and decrease acid reflux into the esophagus in night. In addition, heartburn sufferers can adjust the height of their bed, possibly using pillows, so that the stomach rests below the chest, allowing gravity to help keep its contents out of the esophagus. Patients should also stop smoking to not only decrease GERD’s effects but to decrease the chance of developing other types of cancer.

Much of the current medical treatment for Barrett’s esophagus has focused on treating GERD, which can lead to the condition. Histamine receptors have been a popular therapy to treat GERD and mild esophagitis since the 1970s, and many can be purchased over the counter. These drugs stop acid secretion by blocking the histamine receptors in the stomach’s acid- producing cells.

If the GERD becomes more severe and complicated — including Barrett’s esophagus — patients may be treated with proton pump inhibitors, which disable the acid pump of the stomach’s acid-producing cells. This stops acid secretion and can also reduce the bile reflux into the esophagus.

In addition to medication, endoscopic therapies have emerged for GERD treatment since becoming available for clinical use in 2000. The procedure tightens or thickens the area near the gastroesophageal junction to keep the acid and bile in the stomach from escaping into the esophagus.

Into the Future

There has been a boom in research in recent years in how to diagnose and treat Barrett’s esophagus and its associated cancer. For example, University of Washington researchers developed a pill-sized camera to hunt for cancer symptoms in the lower esophagus. The camera was designed to take high-quality, color pictures in small spaces. The technical term for the device is the tethered-capsule endoscope. Its small size means the patient doesn’t have to be sedated during the procedure, and the tethered cord allows doctors to control its movement. The tiny endoscope is encased in a pill, which is tethered to a 1.4 mm-wide cord. The procedure could develop into a low-cost alternative to the traditionally expensive upper endoscopy. The lower cost, however, also means a lower-quality picture compared to traditional endoscopic techniques.

Medical device company Boston Scientific has revamped its biopsy forceps to extract larger tissue samples to help better diagnose Barrett’s esophagus. The Radial Jaw 4 Biopsy Forceps have a new jaw design and new micro-mesh tooth configuration to take larger samples without the need to use large-channel, therapeutic endoscopes. In addition, jumbo forceps such as the Radial Jaw 4 Jumbo Biopsy Forceps are suited for surveillance biopsies of Barrett’s esophagus because of the increased jaw size and its work in tighter areas. According to Boston Scientific, these single-use forceps, unlike reusable forceps, are designed to eliminate the risk of transmitting patient to patient disease.

Canadian researchers in Edmonton, Alberta, are looking into laser treatments — called photodynamic therapy — as a way to not only fight esophageal cancer, but to possibly ward off Barrett’s esophagus as well. Prior to the laser treatment, patients are given an agent called Photofrin, which acts as a dye that is absorbed into abnormal cells but not normal cells. Two days later, doctors insert a laser down the esophagus, which activates the agent and causes the cancerous cells to die off. The researchers said the procedure is 80 percent effective for patients with Barrett’s esophagus. The procedure, however, can be costly, with the agent alone costing as much as $4,000 per patient.

BarrX Medical Inc. reported early last year that its therapy, the HALO360 Ablation System, cured 70 percent of patients of Barrett’s esophagus one year after the treatment. In the study, patients with the earliest stages of Barrett’s esophagus were treated with the BarrX system, which is a balloon-based radiofrequency device designed to remove the diseased cells using controlled heat. The procedure is performed with an endoscope and uses radiofrequency to generate a localized area of heat for less than one second in the Barrett’s area and destroys the abnormal lining.

However, much is still unknown about Barrett’s esophagus. HHS says there needs to be more research into identifying people with the problem, discovering what causes it, testing treatments that could prevent or eliminate it, and finding better treatments for people who have Barrett’s esophagus and cancer. This way, at the very least, people can see the warning signs before it’s too late.

For more information about imaging, specifically for Barrett's esophagus, visit the following link.
  http://www.endonurse.com/hotnews/techniques-imaging-diagnosis-barretts.html

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