Barrett’s esophagus is a condition in which the esophageal lining changes as a direct result of chronic reflux of gastric contents into the lower esophagus. The condition was first described by Norman Barrett, a British surgeon, who noticed a discoloration in the lower esophagus of his patients who were undergoing surgery for reflux and hiatal hernia repair. The condition is important because it is felt to be the major risk factor for the development of esophageal adenocarcinoma.
Barrett’s esophagus is believed to be caused by chronic reflux of gastric contents which results in inflammation and subsequent metaplasia (a change in the lining) of the lower esophagus. This change allows the area to be better protected against chronic acid and gastric content exposure and is more similar to the lining found in the stomach and the small bowel.
Barrett’s esophagus per se may not have any specific symptoms but patients make complain of chronic reflux symptoms including heartburn and regurgitation. In patients who are developing a mass or nodule arising from within the Barrett’s esophagus region, suggestive of the transformation of the area into a cancer, difficulties in swallowing, or dysphagia, may develop as well.
Barrett’s esophagus is typically diagnosed via endoscopy. The endoscopist will usually see a change in the color of the lining of the lower esophagus, usually a salmon colored appearance. However, this visualization alone is not enough to make the diagnosis. Biopsies of this region of tissue in the esophagus must be obtained and show evidence of intestinal metaplasia, defined as the visualization of a specific type of cell, known as a goblet cell, under a microscope. Thus, Barrett’s esophagus can be suspected during endoscopy but the presence of intestinal metaplasia must be confirmed by a biopsy before an official diagnosis of this condition can be made.
Most patients with Barrett’s esophagus without evidence of any dysplasia have a low risk of developing cancer and can be observed with periodic follow-up endoscopies every 3 to 5 years in which biopsies are obtained to sample the mucosa to check for the development of dysplasia over time. For those with a greater risk of developing cancer, such as the development of dysplasia, a variety of treatment techniques have been developed over the past two decades. These techniques have been shown to be safe and effective in eliminating dysplasia and all Barrett’s esophageal tissue in the vast majority of patients. Collectively they are referred to as endoscopic eradication therapy (EET).
EET techniques are typically divided into two groups. The first involve resection procedures that cut out the abnormal tissue such as endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD). The second includes a variety of ablation technologies which typically either burn or freeze the Barrett’s tissue. These techniques have included radiofrequency ablation (RFA), cryoablation, argon plasma coagulation (APC), photodynamic therapy (PDT) and multipolar electrocoagulation (MPEC). Of these, the combination of RFA and EMR are the best studied and most widely utilized methods of EET. Typically, the resection techniques are used first to eliminate any and all nodular and visibly distinct lesions. The remainder the Barrett’s tissue is then ablated, usually with RFA and less frequently with cryoablation. Although these techniques are highly effective, patients undergoing EET will still need to control their GERD with medications or via an anti-reflux procedure to avoid recurrence of the Barrett’s esophagus. This risk of recurrence is about 15% and patients who have received EET will require follow-up endoscopies for a period of time to check to make sure the Barrett’s tissue has not redeveloped.