This interesting article by Dr. Michael Kimbrell, For The Lancaster News
concerns testing to help determine if you have Barrett’s esophagus
If you have had chronic heartburn, indigestion, difficulty swallowing or have gastro-esophageal reflux disease, you may need evaluation for a pre-malignant condition known as Barrett’s esophagus.
Barrett’s esophagus is the most severe consequence of chronic gastro-esophageal reflux. The mechanism by which this happens is unclear, but the usual tissue covering the lower esophagus is replaced by tissue that is more like the tissue in the stomach. The esophagus is normally covered by squamous epithelium, but in Barrett’s esophagus, this is replaced by columnar epithelium. The columnar epithelium is more resistant to the effects of the reflux of stomach acid.
This might seem like a good thing to protect the esophagus from the acid reflux. However, this has been shown to be a pre-malignant condition. Numerous studies have established the association between Barrett’s columnar epithelium and adenocarcinoma (cancer) of the esophagus. Therefore, the development of Barrett’s esophagus is considered a pre-cancerous condition.
The change from normal to cancer develops over time and there is a progression from metaplasia to dysplasia to cancer. These terms refer to the tissue changes that develop in this condition. This provides an opportunity to detect pre-cancerous changes and provide treatment, hopefully before cancer develops.
Esophageal cancer has a poor prognosis if it is not detected early.
Studies show that the risk of developing esophageal cancer in Barrett’s esophagus is increased 30 to 50 times over the risk in the general population. Barrett’s epithelium has been observed in 8 to 20 percent of patients with reflux esophagitis and in 44 percent of patients with esophageal strictures. Since about 5 percent of people above age 55 have gastro-esophageal reflux disease, there are many people who likely have undiagnosed Barrett’s esophagus. Also, since Barrett’s esophagus occurs 10 times more frequently in men than in women, men with chronic reflux symptoms are at greater risk of esophageal cancer than women.
Barrett’s esophagus can only be definitely diagnosed by biopsies of the esophagus. These biopsies are done at the time of an endoscopic examination of the esophagus.
Does everyone with esophageal reflux require endoscopic evaluation? Not necessarily. Persons over age 55 with chronic reflux symptoms, worsening problems with reflux, difficulty swallowing, pain with swallowing, weight loss associated with reflux, food sticking or problems with aspiration should consider having an evaluation for Barrett’s esophagus.
There are three ways to evaluate the esophagus: X-ray, endoscopy and “pillcam.” Each has advantages and disadvantages.
X-ray, or barium swallow, allows a look at the esophagus and can suggest reflux disease, diagnose strictures and suggest other esophageal disorders. Biopsies cannot be done and Barrett’s esophagus cannot be definitely detected. The esophageal “pillcam” or capsule endoscopy allows photographs to be taken of the esophagus and can diagnose reflux and can indicate Barrett’s esophagus. This can be done to determine if endoscopy should be done. It doesn’t require sedation and takes only 20-30 minutes, so little time from work is required. Biopsies cannot be done, so Barrett’s cannot be definitely diagnosed.
Endoscopic evaluation of the esophagus is the gold standard and should be done if there is strong indication of Barrett’s esophagus. This requires sedation and time missed from work, but allows biopsies and photographing of the esophagus.
Once Barrett’s esophagus is diagnosed, surveillance for changes indicating a progression to a pre-cancerous or cancerous condition should be begun. Since there is a progression from benign to pre-malignant to malignant tissue, regular endoscopic evaluations with biopsies are done to determine if surgical treatment is required.
Unfortunately no treatment is known to reverse the changes of Barrett’s esophagus. Aggressive anti-reflux measures should be undertaken, but if pre-cancerous changes develop, esophageal surgery is indi- cated. If there are no changes to suggest pre-cancerous tissue, endoscopy should be done every one to two years.
If suspicious tissue is present endoscopy and biopsies may be required every six months.
If high-grade dysplasia develops and the person is a good surgical risk, esophageal surgery is indicated.
Since this condition is so common and since there is an association with a highly lethal malignancy, people should be aware of this disorder so that they can undergo an evaluation to determine if their reflux disease is or is not associated with Barrett’s esophagus.
Dr. Michael Kimbrell practices internal medicine at Palmetto TriCounty Internal Medicine. He has been an active member of the medical staff at Springs Memorial Hospital for 22 years.
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