Barrett's Esophagus: Endoscopic Surveillance and Treatment Options
Q: I was diagnosed with Barrett's Esophagus a few years ago and have been feeling great on Prilosec without any heartburn. My internist suggested I have another endoscopy. Is it really necessary?
A: Barrett's esophagus is a condition of the esophagus in which the cells lining the esophagus transform from a pink, squamous cell to a salmon colored columnar cell. It is believed to occur as a result of acid damage to the end of the esophagus and occurs in up to 10% of patients with heartburn.
Interestingly, the body most likely does this as a protective mechanism. Columnar cells are typically found in the stomach and, therefore, are more resistant to acid. That's why patients with Barrett's esophagus may experience improvement in their symptoms.
But it's a false benefit. Once Barrett's esophagus develops, there is roughly a 10% chance of developing esophageal cancer over time. The columnar cells in the end of the esophagus can undergo transformation by developing dysplasia, which is a pre-cancerous change in the esophagus. This transformation typically occurs slowly, progressing from Barrett's without dysplasia, to low-grade dysplasia, then high-grade dysplasia and finally esophageal cancer. It is every important to have the esophagus followed with surveillance endoscopies, even in the absence of symptoms, to ensure that the transformation to esophageal cancer is not developing. Typically, if there is no dysplasia present, your doctor will recommend endoscopy every 2 to 3 years. If however, there is dysplasia, depending on the degree; your doctor will work with you to take steps to prevent the development of cancer. Usually, if low-grade dysplasia is present, more aggressive treatment with twice-a-day Prilosec will be recommended, and endoscopy will likely be performed every 3 to 6 months to ensure stability. If high-grade dysplasia develops, more aggressive action will need to be taken.
Q: Will acid reflux medications used to treat heartburn make my Barrett's Esophagus go away?
A: No. Studies have shown that none of the medications used to treat gastroesophageal reflux disease (GERD), including Prilosec, Nexium, other proton pump inhibitors and H2 receptor blockers can reverse Barrett's esophagus. While these medications typically will result in improvement in symptoms, they will not change the cells in the esophagus and therefore will do nothing to stop the possible progression to dysplasia or esophageal cancer. Additionally, surgical repair of a hiatal hernia, although likely to result in improvement in symptoms of GERD, will also not reverse Barrett's esophagus. It therefore cannot be stressed enough, that even in the absence of symptoms, patients with Barrett's esophagus need to undergo surveillance endoscopy.
Q: I have Barrett's Esophagus and was recently found to have high-grade dysplasia on an upper endoscopy. What are my treatment options?
A: There are many treatment options available for patients with Barrett's esophagus with high-grade dysplasia. Although most definitive, surgical treatment via esophagectomy (removal of part of the esophagus) for Barrett's with high-grade dysplasia is a controversial and very aggressive surgery. Typically patients will be hospitalized for over two weeks, and there is a high incidence of pneumonia, infection and heart attack. Depending on your age and other medical problems, there are several options available. While I will list a few of them briefly here, it is very important to discuss these with your physician. Additionally, most of these procedures are not done at community hospitals and only at specialized academic centers. This should also be discussed with your gastroenterologist and proper referrals to these institutions should be made when appropriate.
Ablation. Removal of dysplasia, or ablation, makes can reverse Barrett's esophagus and it may prevent esophageal cancer. Combined with medication, ablation may be appropriate especially if you're not a good candidate for an esophagectomy. Ablation procedures include:
_Photodynamic therapy (PDT)._First, you'll be injected with a drug called porfimer sodium (Photofrin) that makes the Barrett's cells sensitive to light. Then, your doctor inserts a specialized light source into your esophagus. The light causes a reaction with the Photofrin that destroys Barrett's cells.
Electrocautery. Your doctor inserts an electric wire into your esophagus to burn away dysplasia.
Laser therapy. Your doctor uses a hot beam of light (laser) inserted into your esophagus to burn away Barrett's cells.
_Argon plasma coagulation._Your doctor releases a jet of argon gas into your esophagus along with an electric current to burn away dysplasia.
Endoscopic mucosal resection. Using an endoscope, your doctor injects a saline solution under the area of your esophagus that contains dysplasia. A blister forms under these abnormal cells, allowing your doctor to cut or suction the abnormal area away from the underlying tissue without damaging the rest of your esophagus. Your doctor may recommend following this procedure with photodynamic therapy.
We hope you find this general medical and health information useful, but this Q&A is meant to support and NOT replace the professional medical advice you receive from your doctor. For all personal medical and health matters, including decisions about diagnoses, medications and other treatment options, you should always consult your doctor.