Barrett's Esophagus

Understanding Barrett's Esophagus
What Everyone Should Know... +

Barrett's esophagus is a precancerous condition of the esophagus that typically affects white males over 50 years although others may also have this condition. The incidence of the type of cancer associated with Barrett's esophagus has recently dramatically increased in the United States even though Barrett's -associated cancer may be prevented or cured with early diagnosis and treatment. Diagnosis and treatment services for Barrett's esophagus and esophageal cancers are available at Johns Hopkins.

Definition +

Progression SlideBarrett's esophagus is a condition in which the lining of the esophagus changes from its normal lining to a type that is usually found in the intestines.

It is believed that this change is the result of chronic regurgitation (reflux) of the stomach contents up into the esophagus. The contents of the stomach contain digestive acid and other chemicals which damage the normal lining of the esophagus.

In the healing process, the wrong type of cells grow to repair the damaged areas. This phenomenon is referred to as "metaplasia" and, in the case of the esophagus, intestinal metaplasia replaces the normal squamous type cells which line the esophagus. This happens in about 10-15% of people who have long-term reflux.

Barrett's Esophagus Progression

Once the metaplastic cells have replaced the normal ones, the patient frequently feels less discomfort since the metaplastic areas seem to be less sensitive than the normal tissue. Unfortunately, patients with intestinal metaplasia are at increased risk to develop cancer of the esophagus over those without it, so being symptom-free does not equate with being disease- free. As a matter of fact, patients with Barrett's esophagus have a 30-125 fold higher risk of developing cancer of the esophagus than the general population.

Importantly, with proper testing, doctors can detect these cancers early, before they have spread. There are precancerous stages that the metaplastic tissue goes through before the development of cancer, and these precancerous stages are classified as dysplasia (see illustration above). A number of genetic abnormalities have been discovered in this precancerous state. Dysplasia is detected by performing endoscopic biopsies from the esophagus.

Diagnosis +

hiatal hernia The American Gastroenterologic Association advises that individuals who have had reflux symptoms (usually heartburn) for several years undergo upper endoscopy to determine if Barrett's esophagus is present and to assess for premalignant features.

Upper endoscopy is a simple, painless, low risk outpatient procedure requiring less than an hour. This is accomplished by insertion of a slim, flexible tube with a camera at its tip (endoscope) through the mouth into the esophagus. A computer and TV screen provide an image of your esophagus that allows the gastroenterologist to assess for inflammation (esophagitis) and Barrett's esophagus. The diagnosis of Barrett's esophagus is made by biopsy, or sampling of the esophageal lining.

At Johns Hopkins, biopsies are sent to the Division of Gastrointestinal Pathology and microscope slides are prepared from them. These are examined by gastrointestinal pathologists (physicians who specialize in the diagnosis of gastrointestinal diseases using microscopy).

The diagnosis of Barrett's esophagus may be sometimes difficult, particularly when there is a hiatal hernia and small area of abnormal esophageal lining. Some endoscopists also use special non-toxic dyes such as methylene blue to help them identify areas which may harbor abnormal precancerous changes (dysplasia). This technique is called "chromoendoscopy" and, in experienced hands, it can increase the detection rate of Barrett's esophagus or precancerous changes.

Dysplasia +

What is it?
A precancerous condition in which cells which are very similar to cancer cells grow in an organ but have not yet acquired the ability to invade into tissue or metastasize (spread to areas distant from where they started). This is a stage which can be cured.

Treatment for Varying Degrees of Dysplasia:

Barrett's esophagus with: Commonly Recommended Treatment:
Atypia indefinite for dysplasia Patients will need to undergo a repeat endoscopic examination after an 8- to 12-week course of intensive acid suppression.
Low-grade dysplasia (pre-cancerous change) Antireflux therapy (either medical or surgical) is recommended, followed by endoscopic surveillance every 1-3 years.
High-grade dysplasia
(severe precancerous change)
Antireflux therapy plus additional therapy prescribed individually on the basis of histologic findings, coexistent disease, and the operative risks (see below). Additional therapy may include surveillance endoscopy every 3-6 months, photodynamic therapy, endoscopic mucosal resection, or surgery.

Click the two links below to read more about the topics:

  • Identifying Dysplasia using Endoscopy
  • Treatment of High Grade Dysplasia

Medical Treatment +

Medical Treatment for Reflux

The goals of treatments are to:

  • Decrease gastroesophageal reflux,
  • Improve esophageal clearance, and
  • Protect the esophageal lining

These goals can be achieved by certain general measures and specific drug treatments. Treatment controls symptoms and reflux esophagitis but does not result in regression of Barrett's esophagus. Therefore the risk of cancer is not eliminated by any of these treatments.

Traditional advice to patients with uncomplicated cases has been to elevate the head of the bed by using blocks or a foam wedge. This simple procedure can help reduce the reflux that may occur while sleeping. Patients are also advised to lose weight, to avoid eating within 3 hours of bedtime; to cut back on large or high-fat meals. Chocolate, nicotine, peppermint, raw onions, caffeine, alcohol may aggravate reflux and are best avoided.

In mild cases of gastroesophageal reflux, the use of certain over-the-counter and prescription medicines can be indicated. These include histamine H2 receptor blocking agents such as cimetidine (Tagamet), ranitidine (Zantac), famotidine (Pepcid) and nizatidine (Axid) may be needed. Tums, Rolaids, or other quick-acting reflux medications can also be considered. In moderate to severe cases, H2 receptor blockers are used in higher doses.

Prokinetic agents, or drugs that help move food through the gastrointestinal tract more quickly, offer an attractive alternative either alone or in combination with acid inhibition. For example, metoclopramide can be taken 30 min before meals and at bedtime to hasten gastric emptying and improve esophageal clearance.

Proton pump inhibitors

Proton pump inhibitors (PPIs), Prilosec (Omeprazole is available over the counter) and Prevacid, have also been shown to be effective. Histamine H2 receptor blocking agents are less potent suppressors of gastric acid secretion than are PPIs. However, some patients report that when the use of PPI is discontinued, symptoms recur within days. Thus patients often need to continue the PPI on a long-term basis. One drawback to long term PPI treatment is the cost. The safety of long-term use of PPIs is still being investigated. As noted above, treatment with PPIs and the other medications controls symptoms and reflux esophagitis but does not result in regression of Barrett's esophagus. Therefore the risk of cancer is not eliminated.

Reflux eosphagitis requires prolonged therapy for 3 to 6 months or longer if the disease recurs quickly. Endoscopy is needed in patients with persistent or recurrent symptoms of gastroesophageal reflux disease.

Surgery +

Surgical Treatment for Reflux

For some patients with severe reflux disease, an operation is an alternative option to long term use of medication. This applies especially to patients with resistant (at least 6 to 12 months) or complicated reflux esophagitis (with strictures) that does not respond fully to medical therapy or to patients in whom long term medical therapy is not desirable.

laparascopic fundoplication

Usually a laparascopic fundoplication (in which the gastric fundus is wrapped around the esophagus so as to mimic a normal lower esophageal sphincter and prevent reflux) is performed. The laparoscopic (inserting a laparoscope through a tiny incision in the belly) approach has substantially reduced postoperative discomfort in comparison with open thoracotomy (opening the chest to perform surgery) or laparotomy (opening the abdomen). The typical hospital stay at expert centers such as Johns Hopkins is only 1 to 2 days.

Antireflux therapy is effective in controlling the reflux symptoms. However, it does not usually result in reduction in length or grade of Barrett's esophagus. There is still a small risk of developing esophageal cancer. Therefore patients need to be monitored closely and followed up with periodic endoscopic biopsies for the development of dsyplasia (precancerous change) and early adenocarcinomas (cancers). The choice of therapy for Barrett's esophagus mainly depends on the existence and grade of dysplasia (precancerous change).

Esophageal Cancer +

Cancer of the Esophagus

The presence of Barrett's esophagus is associated with increased risk of developing an invasive cancer (adenocarcinoma). Columnar epithelial dysplasia as seen in Barrett's esophagus is a premalignant lesion for adenocarcinoma. Adenocarcinoma does not develop "out of the blue". Instead, adenocarcinoma in Barrett's esophagus develops in a sequence of changes, from nondysplastic (metaplastic) columnar epithelium, through low-grade and then high-grade dysplasia (preancerous change detected under the microscope) and finally invasive cancer. This makes early detection and early treatment a possibility.

Barrett's Esophagus Progression

Patients with Barrett's esophagus have a 30- to 125-fold increased risk of the development of esophageal cancer in comparison with the general population. The disease is most common in white males.

At Johns Hopkins, patients with esophageal cancer are evaluated and treated by members of the Esophageal Multidisciplinary Group. This group consists of cancer specialists from the Departments of Medicine, Oncology, Radiology, Surgery, and Pathology. This group meets weekly to discuss treatment strategies for each patient.

Approximately 30% of the esophageal cancers treated with pre-operative chemoradiation have no residual cancer cells in the excised specimen. These patients have prolonged survival over those treated by surgery alone. There are also several clinical trials currently available for patients with esophageal cancer. Each patient can be offered a trial best tailored to to provide benefits.

The treatment of choice for a biopsy-proven early esophageal cancer is surgical resection where the intrathoracic esophagus (the part in the chest) must be removed. Esophageal adenocarcinomas can spread (metastasize) to any of several lymph nodes (lymph "glands") in the chest. As such, diagnosis of metastatic disease in these lymph nodes is best confirmed prior to surgical resection.

A surgeon is best qualified to assess whether surgery is a possible option. When adenocarcinoma is detected at an early, usually presymptomatic stage in patients with Barrett's esophagus, the chance of surgical cure is high - 50 to 80%.

The current treatment at Johns Hopkins for patients with invasive esophageal cancer is pre-operative chemoradiation followed by surgery. Each patient is staged (evaluated to assess the extent of disease) using various diagnostic tools, including CT scan, MRI, endoscopic ultrasound, and laparascopic examination prior to chemoradiation.

What Does Esophageal Cancer Look Like? High-grade Dysplasia Photo
This specimen is a segment of an esophagus and a portion of the stomach from a patient with high-grade dysplasia in Barrett's esophagus. The esophagus and stomach have been opened and the esophagus is the narrower area on the right of the frame. The inside lining is whitish on the right but appears reddish and velvety closer to the stomach. The reddish area is Barrett's esophagus. There is no tumor (mass) in this specimen, which showed high-grade dysplasia (severe pre-cancerous change) on microscopic examination.

Cancer between Esophagus and Stomach Photo
This specimen depicts a cancer at the area of the junction between the esophagus and stomach. It is a large irregular mass. The objective of endoscopic surveillance in Barrett's esophagus is to detect these processes early on when there is a high probability for cure.

Images for Pathologists +

Grading Dysplasia in Barrett's Esophagus

Based on a Large National Study Centered at Johns Hopkins (click the items below)

  • Introduction
  • Images
  • Follow-up Information
  • Follow-up Images