By Dr Milan Bassan, Gastroenterologist
Barrett’s oesophagus is a condition that develops in the lower part of the oesophagus. It is a response to prolonged acid exposure from gastro-oesophageal reflux disease (GORD).
In Barrett’s oesophagus the cells of the lining of the lower part of the oesophagus change to resemble those of the intestine (a process called intestinal metaplasia). These intestinal type cells are more resistant to acid injury than the normal squamous cells of the oesophagus.
Whilst the change to intestinal type cells does not cause any specific symptoms the main concern is that Barrett’s oesophagus carries a small risk of progressing onto oesophageal cancer (adenocarcinoma).
Barrett’s oesophagus is usually diagnosed at endoscopy to investigate symptoms of GORD (heartburn, regurgitation, difficulty swallowing). It is recognised at endoscopy by the extension of the red velvety lining seen in the stomach above the top of the stomach, replacing the pale glossy lining of the oesophagus. Biopsies are taken of the area to confirm the diagnosis.
The main risk factor for developing Barrett’s oesophagus is GORD. The risk in increased with increasing age, smoking and male sex.
When Barrett’s oesophagus is suspected, close inspection of the area is performed at endoscopy. This is to not only carefully define the extent of the Barrett’s but also to assess for any areas where the lining has nodules or masses as these areas are most likely to contain dysplasia or cancer. The use of advanced imaging technologies (such as iScan that is available on the Pentax endoscopes at the Liverpool Day Surgery) helps better define surface and vascular patterns to help target biopsies to the areas of most concern. If there is a lot of inflammation or ulceration the procedure often needs to be repeated after treatment of reflux as the inflammation can make biopsies hard to interpret.
When biopsies of an area of Barrett’s oesophagus are assessed by a Pathologist they check not only for the characteristic features to confirm the diagnosis but also closely review the samples for the presence of cancer cells or pre-cancerous changes (dysplasia) that may be early (low grade) or advanced (high grade).
The ongoing management of Barrett’s oesophagus depends on the results of the biopsies and in particular if dysplasia if present. If Barrett’s oesophagus is present then acid suppression therapy is usually prescribed. For patients with no dysplasia the American Society of Gastrointestinal Endoscopy (ASGE) guidelines recommend that patients discuss the role of further endoscopy with their Gastroenterologist as the risk of progression to cancer is low (about 3% over ten years). If further endoscopic surveillance is to be undertaken then repeat endoscopy in 3-5 years is recommended (however an early repeat endoscopy in 6-12 months is sometimes considered if there is significant inflammation or to obtain a full set of mapping biopsies). In the setting of low grade dysplasia the endoscopy should be repeated in 6 months with extensive sampling and if low grade changes persist annual surveillance is recommended. The risk of progression from low grade dysplasia to cancer is just under 1% per year. High grade dysplasia generally should have treatment due to the high risk of progression.
High grade dysplasia and selected cases of Barrett’s confined to the oesophageal lining (intramucosal carcinoma) can usually be effectively treated endoscopically. Techniques including endoscopic mucosal resection and radiofrequency ablation can be used to remove or destroy the affected tissue with an excellent safety profile, minimising the need for major surgery. All these treatments are available in the local area. After treatment regular surveillance endoscopy is still required.
Liverpool Day Surgery has an experienced team of endoscopists, anaesthetists and endoscopy nurses to undertake surveillance and diagnostic endoscopy. Procedures are usually done under sedation so that patients are asleep for the procedure but have a rapid recovery. Image enhanced endoscopy is available to help further define and characterise any concerning areas found at endoscopic procedures.