Barrett's Oesophagus

Barrett’s oesophagus is the change of the normal cells in the lower part of the gullet, near the stomach, into a different type of cell under the effect of long-standing reflux. Its most important cause is gastro-oesophageal reflux disease (GORD) continuing over many years. Stomach acid and other stomach contents escaping into the gullet again and again may in time bring about a change in its lining. Barrett’s oesophagus is not cancer; but because it is associated with an increased risk of a cancer of the gullet called adenocarcinoma, certain patients need regular follow-up.

In whom is it seen more often?

Barrett’s oesophagus is seen particularly in people who have had reflux symptoms for a long time. The risk may be increased by factors such as older age, male sex, excess weight or fat around the abdomen in particular, smoking, and a family history of Barrett’s oesophagus or adenocarcinoma of the gullet. Nonetheless, not everyone with reflux develops Barrett’s, and cancer never develops in a significant proportion of those who have it.

What are the symptoms?

Barrett’s oesophagus has no symptoms of its own. Patients’ complaints arise mostly from the accompanying reflux disease. There may be burning in the chest, an acid or bitter taste in the mouth, reflux symptoms worse at night and sometimes difficulty in swallowing.

Assessment is needed without delay where there is new or increasing difficulty in swallowing, unintentional weight loss, signs of bleeding, anaemia or recurrent vomiting.

How is the diagnosis made?

Barrett’s oesophagus is diagnosed by upper gastrointestinal endoscopy (gastroscopy). At endoscopy the areas of the lower gullet that look different from normal are assessed and small tissue samples, or biopsies, are taken from the necessary places.

For a definite assessment not only the endoscopic appearance but the examination of the biopsies by a pathologist matters. The pathologist looks in particular for the pre-cancerous cellular changes called dysplasia.

What does dysplasia mean?

Dysplasia is the gradual loss of their normal structure by the cells in the Barrett’s tissue. It does not mean cancer, but it shows that the risk of cancer developing has increased.

Barrett’s oesophagus is broadly divided into:

Barrett’s without dysplasia: there is no marked pre-cancerous cellular change.

Low-grade dysplasia: there are early abnormal changes in the cells.

High-grade dysplasia: there are advanced cellular changes, closer to the development of cancer.

When dysplasia is found, it is particularly important that the biopsies are confirmed by a second pathologist experienced in this field.

Does Barrett’s oesophagus turn into cancer?

Barrett’s oesophagus increases the risk of adenocarcinoma of the gullet developing; but cancer does not develop in the great majority of patients diagnosed with Barrett’s. The risk rises particularly where dysplasia is present. The aim is therefore not to frighten the patient but to follow up those who need it at suitable intervals so that pre-cancerous changes are caught early.

How is follow-up carried out?

The frequency of follow-up is determined by the length of the Barrett’s segment, the biopsy result, the patient’s age and other risk factors.

In Barrett’s oesophagus without dysplasia, endoscopies are generally carried out at intervals of a few years. The European ESGE guideline advises follow-up about every 5 years where the Barrett’s segment is 1–3 cm, and about every 3 years where it is 3–10 cm. Longer Barrett’s segments are advised to be assessed in experienced centres.

Carrying out an endoscopy alone is not enough at follow-up; careful examination of the gullet and, where needed, biopsies taken according to a standard protocol matter.

What is the treatment?

The first step in treatment is bringing the reflux under control. Acid-suppressing drugs of the proton pump inhibitor (PPI) group are generally used. In patients who are overweight, losing weight, giving up smoking and reducing personal factors that increase reflux are also helpful.

Barrett’s tissue without dysplasia does not need to be routinely ablated or removed. By contrast, if confirmed low-grade or high-grade dysplasia develops, most patients can now be treated by endoscopic methods without the need for major surgery.

What are the endoscopic treatments?

If there is a suspicious or raised area, it can be removed by endoscopic mucosal resection (EMR) or, in suitable cases, by wider endoscopic resection methods.

The Barrett’s tissue that remains can mostly be eliminated by methods such as radiofrequency ablation (RFA). Current guidelines recommend endoscopic eradication treatment in confirmed high-grade dysplasia and in suitable patients with low-grade dysplasia. Some early and superficial Barrett’s-related cancers can also be treated completely by endoscopic means in experienced centres.

Does Barrett’s oesophagus go away completely?

Controlling the reflux reduces symptoms and helps prevent further damage to the gullet; but the Barrett’s tissue already present does not always disappear with medication alone.

With the modern endoscopic treatments used in Barrett’s oesophagus with dysplasia, complete removal of the abnormal tissue may be possible in most patients. Even after successful treatment, however, endoscopic follow-up at set intervals is needed.

What should be done once Barrett’s is diagnosed?

A diagnosis of Barrett’s oesophagus does not mean “I have cancer of the gullet”. The most important facts are the length of the Barrett’s segment and whether dysplasia is present in the biopsy. The follow-up programme suitable for the patient should be determined on those findings by a gastroenterologist.

With regular and properly conducted follow-up, risky cellular changes can usually be detected before they progress to advanced cancer, and treated endoscopically.