Barrett Esophagus

Summary

Barrett's esophagus is a pathological change resulting from chronic gastroesophageal reflux disease (GERD), where the normal stratified squamous epithelium in the esophagus is replaced by gastric columnar epithelium. This metaplastic alteration is linked with a heightened risk of developing esophageal adenocarcinoma.

The clinical evaluation of Barrett's esophagus typically involves an esophagogastroduodenoscopy (EGD) which may display a proximal shift of the squamocolumnar junction (Z-line) from the gastroesophageal junction (GEJ). Confirmatory diagnosis requires a biopsy from the distal esophagus, demonstrating the presence of columnar epithelium and goblet cells.

Management mainly consists of pharmacotherapy with proton pump inhibitors (PPIs) to reduce acid reflux, coupled with modifications in lifestyle such as dietary changes. Continuous surveillance through repeated EGD and biopsy procedures is essential to detect early signs of dysplasia, which could be a precursor to cancerous changes in the tissue.

Definition

Barrett's esophagus is a chronic condition resulting from gastroesophageal reflux disease (GERD). Characterized by metaplastic replacement of stratified squamous epithelium with gastric columnar epithelium in the esophagus, it is a known precursor to esophageal adenocarcinoma. 

Epidemiology

• Age: Mean age is about 55 years.
• Gender: More commonly affects men.
• Race: More prevalent in Whites.

Etiology

• Gastroesophageal reflux disease (GERD).
• Erosive esophagitis.
• Peptic stricture.
• Hiatal hernia.
• Smoking: has a synergistic effect with GERD.
• Central obesity.
• Family history.
• Oral bisphosphonates.

Pathophysiology

• Mucosal injury: Due to chronic reflux of gastric acid.
• Metaplasia: Adaptive response to injury, leading to transformation of one type of differentiated tissue to another.
• Dysplasia: Acid and bile salts causing oxidative DNA damage in epithelial cells, leading to abnormal development and proliferation.

Clinical Presentation

• Symptoms associated with GERD (heartburn, regurgitation, dysphagia, odynophagia).
• Physical exam is usually unremarkable.

Diagnosis

• Screening: Recommended for high-risk patients.
  • Long-standing symptoms (> 5 years)
  • Age > 50 years
  • Smoking history Obesity
  • First-degree relative with esophageal adenocarcinoma
• Esophagogastroduodenoscopy (EGD)
  • Gross findings:
    • Evidence of columnar epithelium
    • Squamocolumnar junction (Z-line, where columnar and squamous epithelium meet in the esophagus)
• Biopsy: Required for definitive diagnosis, includes identifying columnar epithelium and goblet cells.
  • Biopsy findings:
    • Columnar epithelium
    • Goblet cells (mucin-secreting cells, seen in the intestinal mucosa)
    • Gastric foveolar-type cells (mucin-secreting glands, normally seen in the gastric mucosa)

Treatment

The goal is to treat underlying acid reflux using Proton pump inhibitors (PPIs), dietary modifications, weight loss.

• Proton pump inhibitors (PPIs)
  • Preferred over H2-receptor blockers
  • Treatment is indefinite.
  • Common choices:
    • Omeprazole
    • Pantoprazole
• Diet modifications, aiming to avoid:
• Fatty foods
• Acidic foods and drinks
• Caffeine
• Alcohol
• Eating prior to bedtime
• Aviod nonsteroidal anti-inflammatory drugs (NSAIDs)
• Weight loss

Complications

• Esophageal adenocarcinoma: Most significant morbidity ➜ The annual incidence of cancer in patients with Barrett esophagus: 0.1–0.4%
  • Uncommon
  • Helicobacter pylori infection is protective.