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Barrett's esophagus: A consequence of long-term acid reflux

For most of us heartburn is an occasional nuisance, the price we pay for a trip to an all-you-can-eat buffet or other heavy meal. Heartburn usually lasts a short time and is quickly relieved by an over-the counter antacid. But if it occurs two or three times a week, you may have a larger problem known as gastroesophageal reflux disease (GERD), or acid reflux.

More than 15 million Americans, mainly adults, have acid reflux and experience its most common symptom, heartburn, several times a week. Its cause is a faulty valve called the lower esophageal sphincter located between the esophagus – a muscular tube that carries food and liquids from the mouth to the stomach – and the stomach.

“Acid reflux occurs when the lower esophageal sphincter relaxes more frequently than it should. This results in acidic juices from the stomach backing up into the esophagus and damaging its lining,” said Camille F. Torbey, M.D., a gastroenterologist at Marshfield Clinic Marshfield Center.

For some people, heartburn is the only symptom of acid reflux. Others experience excessive throat clearing, problems swallowing, the feeling that food is stuck in the throat or the lower chest, burning in the mouth and burning pain in the chest.

Untreated long-term acid reflux can sometimes lead to more serious health problems. One of these is Barrett’s esophagus, a disease marked by changes in the cells that increase the risk of esophageal cancer.

“Over a period of years, gastric reflux erodes the smooth grayish lining of the esophagus,” Dr. Torbey said. “As a way to protect itself perhaps, the esophagus starts to create a salmon-colored tissue lining with cells that resemble the makeup of the small intestine. At this stage, the change has progressed into the precancerous condition known as Barrett’s esophagus.”

Diagnosis

Barrett’s esophagus cannot be diagnosed by symptoms, through a physical exam, or blood tests. “The only way to diagnose Barrett’s is through a two-part process: an upper gastrointestinal (GI) endoscopy to confirm the presence of abnormal tissue in the esophagus followed by a tissue biopsy,” Dr. Torbey said.

In an upper GI endoscopy, a flexible tube called an endoscope, which has a miniature camera, is passed into the esophagus to examine its tissue. If the tissue appears removal of a small piece of tissue, which is examined under a microscope.

People with Barrett’s are more likely to eventually develop a form of cancer of the mucus-secreting cells of the esophagus, known as esophageal cancer, than people who do not have it. Esophageal cancer often spreads from the esophagus to lymph nodes and other organs. Esophageal cancer is commonly diagnosed late in its course by the time symptoms arise. Therefore, it is rarely curable and carries a poor long-term survival. There are, however, treatments that are available.

“For people with Barrett’s esophagus, there is a small risk of developing esophageal cancer, less than one percent per year,” Dr. Torbey said. “Although the risk is small, we want patients to understand they have an increased likelihood of developing cancer with Barrett’s esophagus,” he added.

Who is at risk?

Barrett’s esophagus is about two to three times more common in men as in women, and more common in white men than men of other races. It is found most often in middle-aged and older adults; the mean age at diagnosis is 55. Although people who do not have heartburn can develop Barrett’s esophagus, it is much more likely to develop in people with chronic acid reflux, according to Dr. Torbey. “We most often see Barrett’s in patients who have had symptoms of acid reflux for about 10 years, especially white middle-aged men,” he said. “We also sometimes see it in the elderly.”

While there are no evidence-based guidelines on who should undergo endoscopy to check for Barrett’s esophagus, Dr. Torbey said that it may be wise for middle-aged adult patients who have had acid reflux for a number of years to be evaluated.

“Nothing has been as predictive of the development of Barrett’s esophagus as duration of symptoms, so there are no hard or fast rules for who should be checked. I would advise patients who have had reflux two to three times a week for five years or longer to consult with their physician,” he said.

For years, tobacco and alcohol use were thought to be contributing factors to the development of Barrett’s esophagus. Dr. Torbey said this is no longer the case. “We encourage patients to make healthy lifestyle modifications, but smoking and drinking alcohol are no longer considered direct factors,” he said.

Available treatments

The standard treatment for both Barrett’s esophagus with high-grade dysplasia, a more advanced precancerous change, and esophageal cancer is surgical removal of the esophagus (esophagectomy). However, surgical patients may experience complications and a lower quality of life and some may not be good surgical candidates due to age or other health problems.

Dr. Torbey said that a newer treatment known as photodynamic therapy, or PDT, was approved in 2003 by the Food and Drug Administration (FDA) for treatment of Barrett’s esophagus with significant precancerous cell changes. PDT is available at Marshfield Clinic Marshfield Center

Dr. Torbey said that patients with an established diagnosis of Barrett’s esophagus will need to undergo medical therapy for the rest of their lives, with strong acid-blocking medications known as proton pump inhibitors to heal inflamed esophageal tissue and help keep symptoms under control.

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