Barrett Esophagus

• • Gastroesophageal reflux disease (GERD)

  • Metaplastic changes from squamous to intestinal-type columnar epithelium in the distal esophagus

  • Metaplasia may contain varying degrees of dysplasia, which is associated with increasing risk of developing esophageal adenocarcinoma

  • Neither medical nor surgical treatment consistently causes regression of metaplastic changes but may prevent progression

Epidemiology

• • Acquired intestinal-type metaplasia of any length that replaces the normal squamous epithelium of the distal esophagus; induced by chronic gastroesophageal reflux

  • Found in 10-20% of patients with gastroesophageal reflux

  • Male:female incidence of 2:1; increasing incidence with increased age

  • Conveys a 2-fold increased risk of developing adenocarcinoma

  • Adenocarcinoma is found in 10% of patients with Barrett epithelium at the time of first endoscopic exam

  • Lower esophageal sphincter pressure averages 5 mm Hg; 24-hour pH monitoring reveals increased esophageal acid exposure and impaired clearing

  • Reflux of bile acids may contribute to the development of Barrett esophagus along with acid and pepsin

Symptoms and Signs

• • Heartburn, milder than in the absence of Barrett changes because the metaplastic epithelium is less sensitive than squamous epithelium

  • Regurgitation

  • Dysphagia

Imaging Findings

• • Esophagoscopy: Pink epithelium in the lower esophagus instead of the shiny gray-pink squamous mucosa; must be verified by biopsy

  • Contrast radiography: Hiatal hernia, esophageal stricture, or ulcer

• • Patients with moderate to severe GERD should undergo endoscopy and biopsy to assess distal esophagus for metaplastic changes

  • Only biopsy proven intestinal-type metaplasia is associated with increased risk of adenocarcinoma

Rule Out

• • High-grade dysplasia

  • Adenocarcinoma

• • Esophagoscopy and biopsy

• • Treatment is the same as for GERD

  • Surgical treatment is fundoplication

  • Metaplastic epithelium rarely regresses after medical or surgical therapy

Surgery

Indications

• • Severe GERD refractory to medical treatment

  • Esophageal strictures and ulcers

  • Esophagectomy for high-grade dysplasia

Medications

• • H2-blocking agents

  • Proton pump inhibitors

  • Antacids

Treatment Monitoring

• • Routine endoscopy and biopsy should be performed every 6-12 months to assess degree of dysplasia

Complications

• • Esophageal ulcer

  • Esophageal stricture

  • Esophageal adenocarcinoma

Prognosis

• • Estimated incidence of adenocarcinoma in patients with Barrett esophagus of 1:100 patient years of follow-up

Prevention

• • Aggressive treatment of GERD

References