Barrett’s esophagus

Definition

Barrett’s esophagus or Barrett’s syndrome is a pathology of the esophagus characterized by gastric metaplasia of the epithelium due to chronic gastroesophageal reflux and the impact of hydrochloric acid on the mucosa. It is a precancerous condition. It is clinically manifested by belching, heartburn, pain behind the sternum, and signs of reflux esophagitis. Esophagogastroscopy with biopsy is considered the gold standard of diagnosis. Also, chromoscopy, manometry, pH-metry of the esophagus, and contrast X-ray examination (esophagography) are indicated. Treatment is conservative (antisecretory and antacid drugs, prokinetics) in case of complicated course – surgical.

General information

Barrett’s syndrome, also known as Barrett’s esophagus, is a severe disease resulting from long-term regular exposure of the proximal esophagus to acidic gastric juice in gastroesophageal reflux disease. The main danger of this pathology is the frequent development of esophageal adenocarcinoma against the background of esophageal epithelial metaplasia. 

It is currently known that Barrett’s esophagus develops, according to different data, in 1-80% of patients with gastroesophageal reflux disease (GERD), and the incidence of the disease has a direct correlation with age and duration of reflux history. Most often, the disease occurs between 45 and 65 years of age; men are two to five times more often than women; in malignization of Barrett’s esophagus, the ratio of men to women is 9:1.

Causes

The main etiologic factor of Barrett’s syndrome is GERD. In this disease, acidic gastric contents constantly regurgitate into the lower esophagus, damaging the esophageal epithelium and its metaplasia. At the same time, intestinal, fundal, and cardiac glands can be identified in the esophagus. The most likely mucosal cell degeneration in patients with relaxation of the cardiac sphincter, increased acidity of gastric juice, inhibition of epidermal growth factor secretion, and failures ofepithelial proliferation. Esophageal cancer in patients with Barrett’s syndrome is almost 100 times more common than in the general population. The substrate for the formation of cancer cells is high-grade epithelial metaplasia – it takes about four years to form, and 6-20 months are usually sufficient for metaplastic cells to turn into cancer cells.

Most often, the occurrence of Barrett’s esophagus in patients with GERD is caused by worsening living conditions, smoking, and alcohol consumption in any quantities, and taking certain medications against the background of reflux esophagitis. Risk factors include male gender, reflux history of over five years, age over 50 years, and repeated recurrences of reflux esophagitis within a year. The disease is more severe when pancreatic enzymes and bile enter the esophagus, and metaplasia progresses faster. In the initial stages of Barrett’s syndrome, migration of cylindrical gastric epithelium into the esophagus is a protective reaction since such mucosa is less exposed to the aggressive effects of an acidic environment. 

Cylindrical epithelium can usually migrate beyond the Z-line (the border between the esophagus and stomach) within 2 cm, but metaplasia proximal to 2.5 cm from the cardiac sphincter can be detected after several biopsies, allowing the patient to be diagnosed with Barrett’s syndrome.

Symptoms of Barrett’s esophagus

The difficulty in diagnosing Barrett’s syndrome is that its clinical signs are entirely due to gastroesophageal reflux disease, and the disease can be detected only after a biopsy of the epithelium. The most frequent complaint (presented by 75% of patients) is heartburn due to prolonged exposure to the stomach’s acidic environment on the esophageal mucosa. Heartburn occurs more often after eating, physical exertion, and torso bending. Similar pathogenesis has a similar pathogenesis and the occurrence of belching with acid, bile, or air. Regurgitation of food masses from the stomach into the oral cavity develops due to marked relaxation of the cardiac sphincter, which can no longer hold the contents of the stomach cavity.

Dysphagia is much less common: it usually occurs with severe metaplasia, and its worsening, accompanied by vomiting and bleeding, may indicate esophageal adenocarcinoma. Barrett’s syndrome is often associated with erosive esophagitis, which is accompanied by chronic bleeding, anemia, and emaciation. In addition, symptoms such as dysphagia, bleeding, anemia, and cachexia are usually indicative of esophageal cancer.

Diagnosis

When the first signs of GERD appear, it is necessary to consult a gastroenterologist. The gold standard for diagnosing reflux esophagitis is esophagogastroscopy with endoscopic biopsy of foci of altered epithelium. During esophagoscopy, metaplastic areas of the mucosa are visualized in the form of hyperemic tongues spreading from the Z-line in the proximal direction for more than 2.5 centimeters. For accurate diagnosis, it is necessary to perform a biopsy from four pathologic sites to perform chromoscopy of the esophagus and stomach. Esophageal radiography, GI impedancemetry, esophageal manometry, and intraesophageal pH-metry are also performed to differentiate pathology and detect complications. Stool analysis for hidden blood allows you to identify internal bleeding from the upper parts of the digestive tube.

Morphologic examination of biopsy specimens in Barrett’s syndrome usually reveals elements of gastric epithelium in the esophageal mucosa (cylindrical epithelial cells, fundal, cardiac, and intestinal glands). Given the hereditary predisposition to Barrett’s syndrome and esophageal adenocarcinoma, it is recommended that the level of markers of esophageal dysplasia in the blood be studied.

The absence of signs of epithelial metaplasia in biopsy specimens does not allow Barrett’s syndrome to be excluded in a patient. Quite often, biopsy of the affected areas of the mucosa is difficult due to increased esophageal peristalsis, reflux of gastric contents, and small and scattered location of pathologic areas. Such patients are recommended to have dynamic endoscopist consultations with repeated esophageal biopsies.

Treatment of Barrett’s syndrome

To date, the optimal treatment methods for Barrett’s syndrome, allowing complete regression of clinical manifestations and histologic changes, are still under development.

Therapeutic tactics for Barrett’s syndrome depend on the stage of the disease and the severity of symptoms. In mild and moderate epithelium metaplasia, treatment consists of eliminating clinical manifestations of gastroesophageal reflux, restoring normal esophageal epithelial cover, and preventing malignant degeneration.

To treat GERD, non-medicinal therapy is used. Non-medicinal methods include normalization of daily regimen and diet, treatment of obesity, sleeping in a semi-sitting position, avoidance of bad habits, tight belts, and excessive physical exertion.

Drug therapy includes antisecretory drugs (proton pump blockers, in case of their intolerance – H2-histamine receptor blockers), antacids, and prokinetics (metoclopramide, domperidone). The most significant effect of drug treatment is achieved with a combination of these three groups of drugs. If there are complaints of bloating and an overfilling stomach after eating, enzyme preparations that do not contain bile acids are used.

Studies in the field of gastroenterology show that patients who have been receiving antisecretory and antacid drugs for an extended period before the detection of this disease have a significantly shorter segment of Barrett’s esophagus and a significantly lower level of metaplasia than patients who have not used these medications.

Indications for surgical treatment of Barrett’s syndrome are esophageal strictures, a high degree of metaplasia, therapy-resistant esophageal ulcer, esophageal bleeding, and a high risk of malignization. Endoscopic techniques destroy metaplastic epithelium: photodynamic, laser, and plasma argon therapy; electrocoagulation and cryodestruction; and endoscopic resection of the esophageal mucosa. In severe cases, patients are indicated total esophagectomy with further reconstruction of the esophagus.

All these treatment options are available in more than 550 hospitals worldwide (https://doctor.global/results/diseases/barretts-esophagus). For example, Total esophagectomy can be performed in 23 clinics across Turkey for an approximate price of $13.1 K (https://doctor.global/results/asia/turkey/all-cities/all-specializations/procedures/total-esophagectomy). 

Prognosis and prevention

The prognosis when Barrett’s syndrome is detected is unfavorable. In patients with a long segment of metaplastic esophagus, esophageal cancer is diagnosed in 0.5-1% of cases; with a short segment of metaplasia, the incidence of malignization is much lower. At the short segment of Barrett’s syndrome and low degree of metaplasia, complete regression of the endoscopic picture on the background of conservative treatment is possible in 8% of patients. Anti-reflux surgery leads to recovery in about 4% of patients.

It is possible to prevent the development of Barrett’s syndrome only through timely diagnosis and treatment of gastroesophageal reflux disease. Specific prevention of Barrett’s esophagus has not been developed. Patients with Barrett’s syndrome, even after effective conservative and surgical treatment, require annual endoscopic examination with a biopsy of the epithelium.