History

Fact Explanation
Diagnosed incidentally on screening Barrett esophagus is the metaplasia of the lower esophageal squamous epithelium in to columnar epithelium(gastric-fundic type, cardia-type, or intestinal-type). It is commonly seen in middle aged males. Barrett esophagus is the precursor of esophageal adenocarcinoma and the risk of adenocarcinoma is about 0.4–0.5% per year. Males and patients with long segment Barrett esophagus are at higher risk. [1,2,5,7]
Asymptomatic Some patients with Barrettt esophagus are asymptomatic. [1,2,3]
History of gastroesophageal reflux disease (GERD) Barrett esophagus is secondary to long term exposure to gastric acid contents in patients with gastroesophageal reflux disease (GERD). Patients have a history of acid regurgitation into the mouth and heartburn. [1,4,6]
Dysphagia Some patients with Barrett's esophagus can have dysphagia if a stricture is present. Stricture is usually due to esophageal scarring. [5]
References
  1. SHARMA P. Are screening and surveillance for Barretttt's oesophagus really worthwhile?. Gut [online] 2005 March, 54(suppl_1):i27-i32 [viewed 19 July 2014] Available from: doi:10.1136/gut.2004.041566
  2. KUIPERS EJ. Barretttt Esophagus and Life Expectancy: Implications for Screening? Gastroenterol Hepatol (N Y) [online] 2011 Oct, 7(10):689-691 [viewed 19 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3265012
  3. GERSON LAUREN B., SHETLER KATERINA, TRIADAFILOPOULOS GEORGE. Prevalence of Barretttt's esophagus in asymptomatic individuals. Gastroenterology [online] 2002 August, 123(2):461-467 [viewed 19 July 2014] Available from: doi:10.1053/gast.2002.34748
  4. SHARIFI ALIREZA, DOWLATSHAHI SHAHAB, MORADI TABRIZ HEDIEH, SALAMAT FATEMEH, SANAEI OMID. The Prevalence, Risk Factors, and Clinical Correlates of Erosive Esophagitis and Barretttt’s Esophagus in Iranian Patients with Reflux Symptoms. Gastroenterology Research and Practice [online] 2014 December, 2014:1-5 [viewed 19 July 2014] Available from: doi:10.1155/2014/696294
  5. OWEN W. Dysphagia BMJ [online] 2001 Oct 13, 323(7317):850-853 [viewed 19 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1121392
  6. MINATSUKI CHIHIRO, YAMAMICHI NOBUTAKE, SHIMAMOTO TAKESHI, KAKIMOTO HIKARU, TAKAHASHI YU, et al. Background Factors of Reflux Esophagitis and Non-Erosive Reflux Disease: A Cross-Sectional Study of 10,837 Subjects in Japan. PLoS ONE [online] 2013 July [viewed 19 July 2014] Available from: doi:10.1371/journal.pone.0069891
  7. BOOTH CL, THOMPSON KS. Barrett's esophagus: A review of diagnostic criteria, clinical surveillance practices and new developments J Gastrointest Oncol [online] 2012 Sep, 3(3):232-242 [viewed 19 July 2014] Available from: doi:10.3978/j.issn.2078-6891.2012.028

Examination

Fact Explanation
BMI Many patients with GERD are obese. Other system examination is usually normal in patients with Barrett esophagus. [1]
Signs of respiratory tract infection Patients with GERD can have respiratory tract infections secondary to aspiration of gastric contents in to the bronchi. Patients are febrile, and have evidence of pulmonary consolidation. Commonly over the base of the right lung. [2]
References
  1. MURRAY L.. Relationship between body mass and gastro-oesophageal reflux symptoms: The Bristol Helicobacter Project. International Journal of Epidemiology [online] 2003 August, 32(4):645-650 [viewed 19 July 2014] Available from: doi:10.1093/ije/dyg108
  2. KHAN AN, AL-JAHDALI H, AL-GHANEM S, GOUDA A. Reading chest radiographs in the critically ill (Part II): Radiography of lung pathologies common in the ICU patient Ann Thorac Med [online] 2009, 4(3):149-157 [viewed 19 July 2014] Available from: doi:10.4103/1817-1737.53349

Differential Diagnoses

Fact Explanation
Erosive esophagitis Erosive esophagitis is another complication of long term GERD. The diagnosis can be made by upper gastrointestinal endoscopy due to the presence of superficial esophageal erosions and evidence of epithelial inflammation. [1,5]
Peptic ulcer disease Burning type of epigastric pain occurs in peptic ulcer disease. Upper gastrointestinal endoscopy is useful in locating the site of the ulcers. Helicobacter pylori is a recognized etiology of the disease. [2]
Hiatus hernia Hiatus hernia is a significant risk factor for the development of GERD. It prevents the proper closure of the lower esophageal sphincter allowing acid reflux in to the esophagus. [1]
Esophageal stricture Benign and malignant esophageal strictures can cause dysphagia. Upper gastrointestinal endoscopy and barium swallow test are useful preliminary investigations, that will demonstrate the stricture. [3]
Carcinoma of the gastric cardia Adenocarcinoma of the gastric cardia can spread to the distal esophagus, mimicking an esophageal adenocarcinoma. [4]
References
  1. SHARIFI ALIREZA, DOWLATSHAHI SHAHAB, MORADI TABRIZ HEDIEH, SALAMAT FATEMEH, SANAEI OMID. The Prevalence, Risk Factors, and Clinical Correlates of Erosive Esophagitis and Barretttt’s Esophagus in Iranian Patients with Reflux Symptoms. Gastroenterology Research and Practice [online] 2014 December, 2014:1-5 [viewed 19 July 2014] Available from: doi:10.1155/2014/696294
  2. SCHARSCHMIDT BF. Peptic ulcer disease. Pathophysiology and current medical management. West J Med [online] 1987 Jun, 146(6):724-733 [viewed 19 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1307465
  3. KIM JH, SHIN JH, SONG HY. Benign Strictures of the Esophagus and Gastric Outlet: Interventional Management Korean J Radiol [online] 2010, 11(5):497-506 [viewed 19 July 2014] Available from: doi:10.3348/kjr.2010.11.5.497
  4. SONS HU, BORCHARD F. Cancer of the distal esophagus and cardia. Incidence, tumorous infiltration, and metastatic spread. Ann Surg [online] 1986 Feb, 203(2):188-195 [viewed 19 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1251068
  5. HA NR, LEE HL, LEE OY, YOON BC, CHOI HS, HAHM JS, AHN YH, KOH DH. Differences in Clinical Characteristics between Patients with Non-Erosive Reflux Disease and Erosive Esophagitis in Korea J Korean Med Sci [online] 2010 Sep, 25(9):1318-1322 [viewed 19 July 2014] Available from: doi:10.3346/jkms.2010.25.9.1318

Investigations - for Diagnosis

Fact Explanation
Upper gastrointestinal endoscopy (UGIE) [1,2] UGIE can detect the dysplastic epithelium by the presence of salmon-pink colored luminal extensions (“tongues”) of mucosa. If the dysplastic segment is more than 7cm it is called a long segment Barrett and if less than 7cm it is called short segment Barrett esophagus. [3,5]
24 hour esophageal PH monitoring This test can detect the presence and the degree of gastroesophageal reflux. Patients with short segment Barrett esophagus have reflux only during the upright position. Patients with long segment Barrett esophagus have demonstrable reflux in both supine and upright positions. [4]
Biopsy of the suspicious lesions Presence of columnar epithelium and goblet cells are indicative of metaplasia of the squamous epithelium. These cells contain large cytoplasmic vacuoles filled with mucin, which are stained blue. [5]
References
  1. SHARMA P. Are screening and surveillance for Barretttt's oesophagus really worthwhile?. Gut [online] 2005 March, 54(suppl_1):i27-i32 [viewed 19 July 2014] Available from: doi:10.1136/gut.2004.041566
  2. KUIPERS EJ. Barretttt Esophagus and Life Expectancy: Implications for Screening? Gastroenterol Hepatol (N Y) [online] 2011 Oct, 7(10):689-691 [viewed 19 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3265012
  3. OWEN W. Dysphagia BMJ [online] 2001 Oct 13, 323(7317):850-853 [viewed 19 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1121392
  4. NEUMANN CS, COOPER BT. Oesophageal pH monitoring in Barrett's oesophagus Gut [online] 2003 Jan, 52(1):153-154 [viewed 19 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1773494
  5. BOOTH CL, THOMPSON KS. Barrett's esophagus: A review of diagnostic criteria, clinical surveillance practices and new developments J Gastrointest Oncol [online] 2012 Sep, 3(3):232-242 [viewed 19 July 2014] Available from: doi:10.3978/j.issn.2078-6891.2012.028

Investigations - Screening/Staging

Fact Explanation
Endoscopic ultrasonography (EUS) When high grade dysplasia is diagnosed EUS is helpful in evaluating the local spread and the surgical resectability of the dysplastic segment. However its use is still controversial. [3,4]
Upper gastrointestinal endoscopy (UGIE) [1,2] UGIE is used in screening of patients with GORD. Biopsy specimens can be obtained from any suspicious lesions for the histological confirmation of the adenocarcinoma. In patients with endoscopic evidence of dysplasia annual endoscopic surveillance is indicated. If the subsequent endoscopies shows no dysplasia for two consecutive years endoscopy is done in every 3 years. Patients with persistent low-grade dysplasia should undergo endoscopic surveillance once in every 6 months intervals for a year and if they shows no progression of the lesions annual surveillance is adequate.
References
  1. SHARMA P. Are screening and surveillance for Barretttt's oesophagus really worthwhile?. Gut [online] 2005 March, 54(suppl_1):i27-i32 [viewed 19 July 2014] Available from: doi:10.1136/gut.2004.041566
  2. KUIPERS EJ. Barretttt Esophagus and Life Expectancy: Implications for Screening? Gastroenterol Hepatol (N Y) [online] 2011 Oct, 7(10):689-691 [viewed 19 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3265012
  3. TRINDADE A. J., BERZIN T. M.. Clinical controversies in endoscopic ultrasound. Gastroenterology Report [online] December, 1(1):33-41 [viewed 19 July 2014] Available from: doi:10.1093/gastro/got010

Management - General Measures

Fact Explanation
Health education Patients with GERD should be advised about the risk of progression in to Barrett esophagus and adenocarcinoma. (0.12% annual risk in patients with Barrett esophagus which increases up to 0.26% in patients with high grade dysplasia.) [4] Obese patients with GERD should reduce weight. Patients should not take heave meals, lie down or bend forwards within about 3 hours of meals. It is better to avoid fatty foods, chocolate, coffee, carbonated beverages, citrus fruit juices, smoking and alcohol. [1,2]
Anti-reflux surgery Patients with symptomatic GERD benefit from anti-reflux surgery, but it is not proven to cause regression of the Barrett's segment. [3]
Management of esophageal strictures Patients with esophageal strictures and dysphagia will benefit from esophageal dilatation. [3]
References
  1. KUIPERS EJ. Barretttt Esophagus and Life Expectancy: Implications for Screening? Gastroenterol Hepatol (N Y) [online] 2011 Oct, 7(10):689-691 [viewed 19 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3265012
  2. GERSON LAUREN B., SHETLER KATERINA, TRIADAFILOPOULOS GEORGE. Prevalence of Barretttt's esophagus in asymptomatic individuals. Gastroenterology [online] 2002 August, 123(2):461-467 [viewed 19 July 2014] Available from: doi:10.1053/gast.2002.34748
  3. OWEN W. Dysphagia BMJ [online] 2001 Oct 13, 323(7317):850-853 [viewed 19 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1121392
  4. Adenocarcinoma in Barrett's Esophagus. N Engl J Med [online] 2011 December, 365(26):2539-2540 [viewed 19 July 2014] Available from: doi:10.1056/NEJMc1113052

Management - Specific Treatments

Fact Explanation
Proton pump inhibitors (PPIs) High dose PPIs are proven to reduce the degree of reflux. So all the patients with GERD should be on PPIs. [2]
Non-steroidal anti-Inflammatory drugs (NSAIDs) and aspirin NSAIDs inhibit the synthesis of prostaglandin E2 which stimulates the growth of the tumor cells, angiogenesis and inhibits apoptosis. By inhibiting the synthesis of prostaglandin E2 NSAIDs reduces the tumor growth and angiogenesis. [2]
Statins Statins inhibit the proliferation of tumor cells and promote apoptosis. [2]
Endoscopic radiofrequency ablation (RFA) RFA is recommended for the treatment of patients with low grade and high grade dysplasia. This procedure carries a risk of developing upper gastrointestinal bleeding and esophageal stricture. RFA is effective in ablating Barrett esophagus. Low grade dysplastic lesions can be successfully ablated than high grade dysplastic lesions by RFA. [1,2,6,7]
Photodynamic therapy (PDT) Some patients develop photosensitivity reactions. [2]
Argon plasma coagulation (APC) APC is commonly used for patients with non-dysplastic Barrett's esophagus. Chest pain is the commonest complication of the procedure. Other uncommon complications include esophageal strictures, fever, bleeding, esophageal perforation and death. [3]
Multipolar electrocoagulation (MPEC) This is another endoscopic treatment option for the treatment of Barrett esophagus. [4]
Endoscopic heater probes Heater probes are used to deliver thermal energy to the dysplastic cells and to cause lysis of tumor cells. [4]
Endoscopic mucosal resection (EMR) [1] EMR is an effective treatment option for the treatment of low-grade dysplastic lesions. All the suspicious, irregular and nodular mucosal areas are resected in this procedure. [2]
Cryotherapy Cryogen (liquid CO2 or liquid N2) is used to cause direct cell injury and cellular freezing. [5]
Esophagectomy Patients with high grade dysplasia may need esophagectomy. However with the development of endoscopic techniques surgical treatment is considered a second line treatment option. Surgical resection also carries an increased morbidity and mortality when compared to endoscopic treatment options. [2]
References
  1. KUIPERS EJ. Barretttt Esophagus and Life Expectancy: Implications for Screening? Gastroenterol Hepatol (N Y) [online] 2011 Oct, 7(10):689-691 [viewed 19 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3265012
  2. BHARDWAJ ATUL, STAIRS DOUGLAS B., MANI HARESH, MCGARRITY THOMAS J.. Barretttt’s Esophagus: Emerging Knowledge and Management Strategies. Pathology Research International [online] 2012 December, 2012:1-20 [viewed 19 July 2014] Available from: doi:10.1155/2012/814146
  3. DEVIERE J. Argon plasma coagulation therapy for ablation of Barretttt's oesophagus. [online] 2002 December, 51(6):763-764 [viewed 19 July 2014] Available from: doi:10.1136/gut.51.6.763
  4. SHARMA P, WANI S, WESTON AP, BANSAL A, HALL M, MATHUR S, PRASAD A, SAMPLINER RE. A randomised controlled trial of ablation of Barretttt's oesophagus with multipolar electrocoagulation versus argon plasma coagulation in combination with acid suppression: long term results Gut [online] 2006 Sep, 55(9):1233-1239 [viewed 19 July 2014] Available from: doi:10.1136/gut.2005.086777
  5. SAPPATI BIYYANI R. S., CHAK A.. Barretttt's esophagus: review of diagnosis and treatment. Gastroenterology Report [online] December, 1(1):9-18 [viewed 19 July 2014] Available from: doi:10.1093/gastro/got015
  6. FALK GW. Update on the Use of Radiofrequency Ablation for Treatment of Barrett Esophagus Gastroenterol Hepatol (N Y) [online] 2013 Jul, 9(7):447-449 [viewed 19 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3736782
  7. AKIYAMA J., ROORDA A., TRIADAFILOPOULOS G.. Managing Barrett's esophagus with radiofrequency ablation. Gastroenterology Report [online] December, 1(2):95-104 [viewed 19 July 2014] Available from: doi:10.1093/gastro/got009