BY-Aman Kailash Setiya

What is Barrett’s Esophagus?The esophagus gets a

tissue lining similar to that of the intestines

The muscle becomes rougher

The cells that are normally found in the intestine replace the normal esophagus cells

Estimated prevalence of Barrett’s esophagus

6-12% of patients who undergo EGD for GERD.

        ● Short-segment BE: 6-12%       ● Long-segment BE: 1-5%

1-2% of unselected patients who undergo EGD Most cases go undetected in the general

population [Autopsy data]. Perhaps 5% of patients with Barret esophagus are currently being diagnosed.

Symptoms of Barretts esophagusThere are no specific

symptoms, they vary per person

Some signs it is likely include:

Constant acid reflux Burning sensations near

chest bonePain in throat and chest

when eating

frequent and longstanding heartburntrouble swallowing (dysphagia)vomiting blood (hematemesis)pain under the breastbone where the

esophagus meets the stomachunintentional weight loss because eating is

painful

Risk factors for developmentof Barrett’s esophagusMale gender 3 times > female gender

White race >> Blacks & Asians

Abdominal adiposity (obesity)

Genetic factors suspected in some patients/families

Chronic reflux symptoms for > 5-10 years

Age >40-50 years; mean age at diagnosis = 55 yrs

Mechanism

Barrett esophagus occurs due to chronic inflammation. The principal cause of the chronic inflammation is gastroesophageal reflux disease, GERD . In this disease, acidic stomach, bile, small intestine and pancreatic contents cause damage to the cells of the lower esophagus

Damage to the squamous esophageal mucosa

Injury heals through a metaplastic process

(columnar cells replace squamous cells)

GERDGERD

Injury healswith restoration ofsquamous mucosa

Long-segment versus short-segment Barrett’s esophagusLong-segment BE (LSBE):  >3-cm segment of distal

esophagus (columnar mucosa with intestinal metaplasia)

Short-segment BE (SSBE):  <3-cm segment (usually tongues or islands of columnar mucosa with intestinal metaplasia)

Patients with LSBE tend to have greater esophageal acid exposure than SSBE, as well as lower LES pressures and more esophageal dysmotility.

LSBE (classic BE) is much better studied.

We are currently managing LSBE and SSBE similarly.

However, questions remain: Does SSBE have the same pathogenesis? Does SSBE have a lower risk of cancer? Does SSBE progress to LSBE? Does the length of BE correlate with cancer risk?

Long segement typeShort segement type

Physiology of Barrett’s EsophagusWhen food becomes

backed up, the juices of the stomach go back up the esophagus.

This is also known as severe acid reflux.

When having a repeated injury to the Esophagus , acidic fluid changes the types of cells lining it from squamous to columnar .(METAPLASIA)

Fluid may contain bile acids.

Development of Neoplasia in Barrett’s Development of Neoplasia in Barrett’s EsophagusEsophagus

1 2 Gastric acid reflu x

2 1 Duodenal bile reflux

Pro - carcinogenic primary and

secondary bile salts

3 pH dependent,

bile

salt induced chronic esophageal injury

4 Chronic esophageal inflammation

and

PGE2 release

5 N eoplasia in Barrett’s

esophagus

Development of esophageal adenocarcinoma from Barrett’s esophagusCompelling evidence exists for a dysplasia-

carcinoma sequence in BE.

Specialized columnar epithelium progresses in some patients → low-grade dysplasia → high-grade dysplasia → adenocarcinoma.

Not every patient with low-grade dysplasia progresses, and low-grade dysplasia can even spontaneously revert back to no dysplasia.

Time course for development of cancer highly variable.

Most patients never progress to dysplasia. Less than 5% of Barrett’s patients will develop cancer.

Why do we care about Barrett’s esophagus?Patients with BE have an increased risk of developing

esophageal adenocarcinoma.

Over the past 30 years, the incidence of squamous cell cancer of the esophagus has stayed constant, while the incidence of adenocarcinoma has increased 6-fold! This is an increase that exceeds that of any other cancer.

Today, adenocarcinoma accounts for more than half of esophageal cancers.

Patients with BE have about a 30-40 fold increased risk of adenocarcinoma of esophagus.

Risk of a BE patient developing cancer is estimated to be about 1 per 200 patient-years follow-up.

Despite all this, most patients with BE do not develop esophageal cancer. [Less than 5%]

DiagnosisGERD is a precursor to

the diagnosis of Barrett’s Esophagus.

The tissue lining of the esophagus has changed.

Endoscopy (a long thin tube that examines the lining of the esophagus and stomach) confirms whether or not cells are abnormal.

1. Locate gastro-esophagealjunction

1. Locate gastro-esophagealjunction

3. Describe extent of metaplasia consistently

3. Describe extent of metaplasia consistently

2. Recognize the squamocolumnar junction

2. Recognize the squamocolumnar junction

Three Essential Steps for Endoscopic Diagnosis and

Description

Therapy of Barrett’s Esophagus

Antisecretory therapy

Surgery

Ablation

Chemoprevention

TREATMENT AND MANAGEMENT TACTICSTREATMENT OF the mai cause that is GERD-

Treatment should improve acid reflux symptoms, and may keep Barrett's esophagus from getting worse. Treatment may involve lifestyle changes and medications such as:

Antacids after meals and at bedtimeHistamine H2 receptor blockers(viz rantidine

famotidine etc)Proton pump

inhibitors(pantoprazole,lansoprazole etc)

N.B.- Lifestyle changes, medications, and anti-reflux

surgery may help with symptoms of GERD, but will not

make Barrett's esophagus go away.

TREATMENT OF BARRETT'S ESOPHAGUSSurgery or other procedures may be

recommended if a biopsy shows cell changes that are very likely to lead to cancer. Such changes are called severe or high-grade dysplasia.

SurgeryRemoval of

intestinal cells from esophagus and replacement of esophageal cells

Removal of the esophagus

Recent advance in surgical methodPhotodynamic therapy (PDT) uses a special

laser device, called an esophageal balloon, along with a drug called Photofrin.

Other procedures use different types of high energy to destroy the precancerous tissue.

Surgery removes the abnormal lining.

Fun and Interesting FactsOnly about 1% of all Americans suffer from

Barret’s Esophagus10% to 15% of people with chronic GERD get

Barrett’s Esophagus.About 3.3 million adults over 50 years of age in

the United States have Barrett’s Esophagus. Men are more likely to develop Barrett’s

Esophagus than women and the ratio is 2:1, and EUROPEAN males are more likely to have it than any other race.

?QUESTIONS?