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Barrett Esophagus

Barrett's Esophagus

Barrett esophagus is a precancerous condition and complication of gastroesophageal reflux disease that predisposes for esophageal adenocarcinoma. Chronic exposure of the esophageal mucosa results in an adaptive response and replacement of stratified squamous epithelium with metaplastic columnar epithelium.


Presentation

Patients suffering from BE are usually of advanced age and have a medical history of chronic GERD. The latter is typically associated with acid regurgitation, heartburn, retrosternal chest pain, and dysphagia. It has been suggested that individuals previously diagnosed with GERD-related erosive esophagitis are more likely to develop BE [5], but these data are primarily of epidemiological relevance since a considerable subset of BE patients remains entirely asymptomatic. Accordingly, it has been recommended to perform annual or biannual esophagoscopy examinations in men who have presented GERD-associated symptoms for more than five years if either two of the following risk factors are present: age >50 years, Caucasian, family history of BE, obesity, smoker [2]. These features define the "classical" BE patient. Eventually, BE may constitute an incidental finding encountered during endoscopic procedures realized for non-related reasons.

Progression to esophageal adenocarcinoma occurs in about 0.5% of BE patients per year [4]. Disease progression may entail additional symptoms like exacerbated dysphagia, persistent cough, weight loss, as well as symptoms associated with metastatic adenocarcinoma [6] [7].

Camping
  • Am J Gastroenterol. 1998 Jul; 93 (7):1033–1036. [ PubMed ] [ Google Scholar ] Paull A, Trier JS, Dalton MD, Camp RC, Loeb P, Goyal RK. The histologic spectrum of Barrett's esophagus.[ncbi.nlm.nih.gov]
  • Mangla, Roger Camp and David Dalton, Agar gel electrophoretic patterns of pepsinogen zymograms in Barrett's esophagus, Biochemical Medicine, 24, 1, (39), (1980). K.[oadoi.org]
  • Paull A, Trier JS, Dalton MD, Camp RC, Loeb P, Goyal RK. The histologic spectrum of Barrett's esophagus. N Engl J Med 1976; 295: 476-80. [ Links ] 13. Chandrasoma P. Pathophysiology of Barrett's esophagus.[scielo.isciii.es]
Candidiasis
  • However, this appearance is nonspecific, and it has been observed in other conditions such as candidiasis, viral esophagitis, superficial spreading carcinoma, and areae gastricae in a small hiatal hernia.[emedicine.com]
Hoarseness
  • Other common symptoms include incessant coughing, hoarseness, or an sore or itchy throat. However some may not experience any symptoms. Unfortunately, people will ignore symptoms and take antacids or continue to use other methods to ease heartburn.[sagastro.com]
  • Some people with GERD have only a sore throat, chronic cough, or hoarseness. Others have no symptoms at all. Plus and Minus Icon Several lifestyle and dietary habits can make gastroesophageal reflux disease continue or worsen.[mskcc.org]
  • Many people who have GERD, Barrett’s esophagus, or both experience symptoms such as heartburn, or a burning sensation in the chest; sore throat; cough; hoarseness; difficulty swallowing; or chest pain.[nyulangone.org]
  • […] the sensation that food is hanging up or not passing down into the stomach properly) Regurgitation of food or liquids, particularly when bending over or laying down, associated with a bitter taste in the mouth Atypical (uncommon) symptoms Chest pain Hoarseness[memorialhermann.org]
  • Esophageal reflux may also cause certain less common symptoms, such as hoarseness or chronic cough, and sometimes provokes conditions such as asthma.[digestive.templehealth.org]
Abdominal Pain
  • These symptoms include: dry cough, frequent heartburn, chest pain, difficulty swallowing food and abdominal pain. These should be evaluated by a gastroenterologist.[manhattangastroenterology.com]
  • Symptoms Common Barrett's Esophagus symptoms Heartburn (burning sensation behind the breast bone) Epigastric pain (upper abdominal pain) Dysphagia (difficulty swallowing or the sensation that food is hanging up or not passing down into the stomach properly[memorialhermann.org]
  • Ho June Song, Kee Don Choi, Hwoon‐Yong Jung, Gin Hyug Lee, Ji Yun Jo, Jeong‐Sik Byeon, Suk‐Kyun Yang, Weon‐Seon Hong and Jin‐Ho Kim, Endoscopic reflux esophagitis in patients with upper abdominal pain‐predominant dyspepsia, Journal of Gastroenterology[oadoi.org]
Odynophagia
  • The major complications were chest pain and odynophagia, which occurred in 57.5% of patients and lasted 3-10 days. Only 3 patients experienced stricture, which was treated easily with dilation.[emedicine.medscape.com]
  • […] however, is associated with these symptoms: frequent and longstanding heartburn trouble swallowing (dysphagia) vomiting blood (hematemesis) pain under the sternum where the esophagus meets the stomach unintentional weight loss because eating is painful (odynophagia[en.wikipedia.org]
  • Obviously, patients with alarm symptoms such as dysphagia, odynophagia, bleeding, or weight loss should be referred promptly for endoscopy. In patients without alarm symptoms, screening guidelines for Barrett’s esophagus are somewhat problematic.[aafp.org]
  • These include lower rates of chest pain, odynophagia, perforation and pneumothorax in comparison with laser and thermal ablation techniques.[bjmp.org]
Deglutition Disorder
  • Disorders Esophageal Diseases Gastrointestinal Diseases Digestive System Diseases Digestive System Abnormalities Gastrointestinal Neoplasms Digestive System Neoplasms Neoplasms by Site Head and Neck Neoplasms[clinicaltrials.gov]
  • Key words Barrett's esophagus Gastroesophageal reflux Adenocarcinoma High grade dysplasia Deglutition Deglutition disorders This is a preview of subscription content, log in to check access. Preview Unable to display preview. Download preview PDF.[oadoi.org]
Pyrosis
  • Populations evaluated Uncomplicated GER Patients had uncomplicated GER if they had: - typical symptoms (heartburn, regurgitation, pyrosis) as a primary complaint; - typical symptoms that were not a primary complaint but elicited during the history; -[hon.ch]
Hematemesis
  • Barrett's esophagus, however, is associated with these symptoms: frequent and longstanding heartburn trouble swallowing (dysphagia) vomiting blood (hematemesis) pain under the sternum where the esophagus meets the stomach unintentional weight loss because[en.wikipedia.org]
Retrosternal Chest Pain
  • The latter is typically associated with acid regurgitation, heartburn, retrosternal chest pain, and dysphagia.[symptoma.com]
Anger
  • INSERM U991, Rennes. 3 INSERM U913. 4 Gastroenterology and Hepatology Department. 5 Virology Department. 6 Gastroenterology, Hepatology and Nutritional Support, University Hospital, Nantes. 7 HIFIH Laboratory, UPRES 3859, SFR 4208, LUNAM University, Angers[ncbi.nlm.nih.gov]
  • France Department of Pediatric Surgery, CHU, Poitiers, France***Department of Pediatric Gastroenterology, Hôpital des Enfants, Bordeaux, France†††Department of Pediatric Gastroenterology, HUDERF, Bruxelles, Belgium‡‡‡Department of Pediatric Surgery, CHU, Angers[ncbi.nlm.nih.gov]
Excitement
  • RESULTS: Based on effective 2-photon excitation fluorescence of cellular reduced pyridine nucleotides and flavin adenine dinucleotide and lack of 2-photon excitation fluorescence of mucin and cellular nuclei, MPM could readily identify and distinguish[ncbi.nlm.nih.gov]

Workup

Diagnosis of BE is based on endoscopic findings and histopathological analyses of biopsy specimens. With regards to the former, metaplastic columnar epithelium is of intense red color and confers a velvety aspect to the esophageal mucosa. In contrast, healthy stratified squamous epithelium appears pale and glossy [8].

BE is frequently referred to as "intestinal metaplasia" because affected mucous membranes resemble small intestinal epithelium. It has to be noted, though, that columnar epithelium as observed in BE patients differs considerably from intestinal mucous membranes, e.g., with regards to gene expression profiles and the cells' ability to differentiate [9]. The pathohistological picture is dominated by pathognomonic mucin-containing acid, Alcian blue-staining goblet cells and periodic acid-Schiff positive cells that harbor neutral mucin [10]. Endocrine and Paneth cells have been identified in samples obtained from BE patients.

If erosive esophagitis is diagnosed at the time of endoscopic examination and biopsy, these diagnostic measures have to be repeated at a later point in time.

Gram-Positive Bacteria
  • The esophageal microbiome is altered in both esophagitis and Barrett esophagus, characterized by a significant decrease in gram-positive bacteria and an increase in gram-negative bacteria in esophagitis and Barrett esophagus.[ncbi.nlm.nih.gov]
Multiple Ulcerations
  • Multiple ulcerations in the region of the stricture are seen. Note the reticular mucosal appearance extending down from the inferior aspect of the stricture.[emedicine.com]

Treatment

  • […] the risk for treatment failure (hazard ratio, 4.24; 95% confidence interval, 1.53-11.7; P 0.005).[ncbi.nlm.nih.gov]
  • Treatment is usually multimodal, combining endoscopic resection of visible lesions with one or more mucosal ablation techniques, followed by long-term surveillance. Such treatment is safe and effective.[ncbi.nlm.nih.gov]
  • The ability to preserve the esophagus with endoscopic mucosal ablation or resection and reduce morbidity of treatment has made endoscopic treatment the mainstay of therapy.[ncbi.nlm.nih.gov]
  • TREATMENT OF GERD Treatment should improve acid reflux symptoms, and may keep BE from getting worse.[nlm.nih.gov]
  • OBJECTIVES: To review current concepts on the pathogenesis, diagnosis, and treatment of Barrett esophagus; to discuss the importance of dysplasia and the role of endoscopic eradication therapy for its treatment; and to review current management guidelines[ncbi.nlm.nih.gov]

Prognosis

  • He underwent transthoracic esophagectomy, extensive lymph node dissection, and cervical esophagogastric anastomosis, but the prognosis was poor. Pathology indicated poorly differentiated adenocarcinoma with BE.[ncbi.nlm.nih.gov]
  • All survived esophagogastrectomy and radiotherapy, but each had metastatic disease and a guarded prognosis.[ncbi.nlm.nih.gov]
  • Current molecular testing for Barrett neoplasia, as well as testing methods currently in development, is discussed, focusing on relevant tests for diagnosing tumor types, determining prognosis, and assessing therapeutic response.[ncbi.nlm.nih.gov]
  • BEA patients with CDO1 gene methylation were shown marginally significantly poorer prognosis (P 0.054) than otherwise patients.[ncbi.nlm.nih.gov]
  • Oesophageal cancers arising in Barrett's oesophagus detected by surveillance are often early and have an excellent prognosis.[patient.info]

Etiology

  • METHODS: The English-language literature relating to tumor epidemiology, etiology, and the pathogenesis of BE was reviewed and summarized.[ncbi.nlm.nih.gov]
  • The etiology of this finding is uncertain, but correlation with the gross surgical specimen in one case suggests that it results specifically from areas of "villous" metaplasia in Barrett epithelium.[ncbi.nlm.nih.gov]
  • Aside from chronic reflux, the etiology of Barrett's esophagus (BE) remains largely unknown. This case-control study investigated body mass index (BMI), central adiposity, and cigarette smoking and risk of BE.[ncbi.nlm.nih.gov]
  • Patients with chronic laryngeal symptoms and no identifiable ear, nose, or throat etiology for those symptoms may benefit from endoscopic screening regardless of whether typical GERD symptoms are present.[ncbi.nlm.nih.gov]
  • The incidence of EAC has increased 350% in the last 3 decades without clear etiology. Finding predisposition genes may improve premorbid risk assessment, genetic counseling, and management.[ncbi.nlm.nih.gov]

Epidemiology

  • Medizinische Klinik, Klinilkum rechts der Isar, Technische Universitaet München, Munich, Germany. 2 Institute of Medical Informatics, Biometry and Epidemiology, Chair of Genetic Epidemiology, Ludwig-Maximilians-Universitaet, Munich, Germany. 3 Institute[ncbi.nlm.nih.gov]
  • We review the presentation, epidemiology, and risk factors for this condition.[ncbi.nlm.nih.gov]
  • METHODS: The English-language literature relating to tumor epidemiology, etiology, and the pathogenesis of BE was reviewed and summarized.[ncbi.nlm.nih.gov]
  • GOALS: To evaluate the association between metabolic syndrome (MetS) and risk of Barrett esophagus (BE) using the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database compared with 2 control groups--Medicare population controls[ncbi.nlm.nih.gov]
  • However, the invasive procedure limits the utility of tumor tissue for epidemiological studies.[ncbi.nlm.nih.gov]
Sex distribution
Age distribution

Pathophysiology

  • Further long-term follow-up prospective study needs to verify the current results, and definite pathophysiological mechanism needs to be further investigated and clearly elucidated.[ncbi.nlm.nih.gov]
  • In: Sleisenger and Fordtran's Gastrointestinal and Liver Disease: Pathophysiology, Diagnosis, Management. 10th ed. Philadelphia, Pa.: Saunders Elsevier; 2016. . Accessed Feb. 17, 2017. Hu Q, et al.[mayoclinic.com]
  • Sleisenger and Fordtran's Gastrointestinal and Liver Disease: Pathophysiology/Diagnosis/Management .10th ed. Philadelphia, PA: Elsevier Saunders; 2016:chap 45. Updated by: Michael M.[nlm.nih.gov]
  • Sleisenger and Fordtran's Gastrointestinal and Liver Disease: Pathophysiology/Diagnosis/Management .10th ed. Philadelphia, PA: Elsevier Saunders; 2016:chap 45. Version Info Last reviewed on: 1/12/2018 Reviewed by: Michael M.[mountsinai.org]

Prevention

  • Regular endoscopic surveillance for dysplasia is the currently recommended cancer prevention strategy for Barrett esophagus, but a high-quality study has found no benefit of surveillance in preventing deaths from esophageal cancer.[ncbi.nlm.nih.gov]
  • Long-term studies will be needed to see if any of these treatments prevent the development of cancer.[texasoncology.com]
  • BETRNet, a multi-disciplinary, multi-institutional collaboration co-sponsored by NCI's Division of Cancer Prevention and Division of Cancer Biology, was established to centralize and enhance efforts to understand Barrett's esophagus (BE) and to prevent[prevention.cancer.gov]
  • Although there is no evidence that medical or surgical therapies to reduce acid reflux prevent neoplastic progression, proton pump inhibitors can be used to help control reflux symptoms.[ncbi.nlm.nih.gov]
  • […] analysis of the pathways leading to chronic inflammation in the esophagus may help to identify biomarkers in patients with Barrett esophagus for neoplastic progression and provide insight into molecular events suitable for therapeutic intervention in prevention[ncbi.nlm.nih.gov]

Summary

Barrett esophagus (BE) may complicate gastroesophageal reflux disease (GERD). In detail, chronic exposure of the esophageal mucosa to gastric acid results in the replacement of stratified squamous epithelium with metaplastic columnar epithelium [1]. In accordance with the disease' etiology, mucosal alterations consistent with BE affect distal portions of the esophagus. However, tissue samples should not be obtained within less than 1 cm of the esophagogastric junction in order to guarantee reliable results [2]. BE is considered a precancerous condition and affected individuals are predisposed for esophageal adenocarcinoma [3].

BE patients are generally prescribed proton pump inhibitors and antacids, and these drugs may alleviate symptoms associated with GERD. Unfortunately, they are unable to reverse structural remodeling processes affecting the esophageal mucosa. Treatment options available to date comprise thermal, photochemical, or mechanical, endoscopic ablation and esophagectomy [4].

References

Article

  1. Estores D, Velanovich V. Barrett esophagus: epidemiology, pathogenesis, diagnosis, and management. Curr Probl Surg. 2013;50(5):192-226.
  2. Falk GW. Updated Guidelines for Diagnosing and Managing Barrett Esophagus. Gastroenterol Hepatol (N Y). 2016;12(7):449-451.
  3. Kalatskaya I. Overview of major molecular alterations during progression from Barrett's esophagus to esophageal adenocarcinoma. Ann N Y Acad Sci. 2016;1381(1):74-91.
  4. McAllaster JD, Buckles D, Al-Kasspooles M. Treatment of Barrett's esophagus with high-grade dysplasia. Expert Rev Anticancer Ther. 2009;9(3):303-316.
  5. Ronkainen J, Talley NJ, Storskrubb T, et al. Erosive esophagitis is a risk factor for Barrett's esophagus: a community-based endoscopic follow-up study. Am J Gastroenterol. 2011;106(11):1946-1952.
  6. Vats HS, Banerjee TK, Resnick J, Khan Q. Esophageal adenocarcinoma arising from Barrett's dysplasia: a case report of double occurrence and prolonged survival after chemotherapy. Clin Med Res. 2006;4(3):184-188.
  7. Triantafyllou S, Georgia D, Gavriella-Zoi V, et al. Cutaneous metastases from esophageal adenocarcinoma. Int Surg. 2015;100(3):558-561.
  8. Spechler SJ. Barrett esophagus and risk of esophageal cancer: a clinical review. Jama. 2013; 310(6):627-636.
  9. Goldblum JR. Barrett's esophagus and Barrett's-related dysplasia. Mod Pathol. 2003;16(4):316-324.
  10. Yamamoto Y, Wang X, Bertrand D, et al. Mutational spectrum of Barrett's stem cells suggests paths to initiation of a precancerous lesion. Nat Commun. 2016;7:10380.

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Last updated: 2019-07-11 21:31