Is it heartburn or is it something more sinister?

The Story of Barrett’s Esophagus

Susan Liberski MD

by Susan Liberski, MD

Heartburn symptoms are very common. Just walk down the aisle of your local grocery or discount store and you’ll see shelves of over the counter (OTC) medications for heartburn and acid indigestion. You probably know the feeling, burning in the chest, discomfort in the upper abdomen, acid taste in the throat. These symptoms can happen after eating late at night or having one too many glasses of holiday cheer at the last cocktail party. Intermittent heartburn, easily relived by OTC agents usually isn’t a health risk or long term problem. However if these symptoms happen frequently, perhaps the problem isn’t heartburn but Gastroesophageal Reflux Disease (GERD).

GERD is also a common condition. It is estimated that about one third of the adult population in the USA suffers from GERD. The disease is characterized by frequent heartburn (one or more times a week) that happens because of inappropriate relaxation of the muscle that  separates the esophagus from the stomach, the lower esophageal sphincter (LES). Our stomachs are designed to produce acid in response to eating to help our food digest. If the LES stays open while the stomach is producing acid, we get the symptoms of GERD.

Lifestyle choices which can make GERD worse include obesity, eating late at night, the use of caffeine, alcohol, chocolate, overly spicy or acidic foods and smoking. Structural changes in the body such as a hiatal hernia (where part of the stomach sits above the diaphragm) or pregnancy can also make GERD symptoms worse. There are also atypical GERD symptoms which include chronic laryngitis, chronic cough and asthma; all a part of the disease called LPR (laryngeal pharyngeal reflux) and these patients may not even have typical heartburn at all.

Common treatments for GERD include lifestyle changes and use of agents such as antacids, histamine receptor antagonists (the H2 Blockerscimetidine, ranitidine and famotidine) or more potent medications like the proton pump inhibitors (PPI- omeprazole, lansoprazole, pantoprazole, rabeprazole, esomeprazole and dexlansoprazole). People who suffer from frequent heartburn and GERD may seek the advice of a gastroenterologist to know which treatment, length of treatment and what further testing is needed to make the patient more comfortable as well as be sure there are no other serious consequences.

Barrett’s esophagus is one of the most serious complications of GERD and can develop in 5-10% of patients with GERD. Barrett’s esophagus is a precancerous condition where the cells lining the esophagus (squamous epithelium) are replaced with cells that look similar to cells in the lining of the small intestine (columnar epithelium).

Although we know that Barrett’s is seen in patients who have GERD, not all Barrett’s patients have frequent GERD symptoms and the development of Barrett’s is not necessarily based on the frequency or severity of symptoms. Barrett’s esophagus increases the risk of adenocarcinoma of the esophagus. Most patients with adenocarcinoma of the esophagus have underlying Barrett’s tissue, however less than one percent of Barrett’s patients develop cancer. It has never been determined what triggers the cells in the esophagus to change into the Barrett’s mucosa and treating GERD with lifestyle changes may not prevent the development of Barrett’s. Obesity, especially belly fat,
alcohol consumption and smoking increase the risk of developing Barrett’s although some authorities also feel our genetics play a major role.

SO HOW IS BARRETT’S ESOPHAGUS DIAGNOSED?

The most reliable way of diagnosing Barrett’s is by performinganEGD(esophagogastroduodenoscopy). This procedure is a lighted tube that is passed down through the mouth into the esophagus, stomach and duodenum. The gastroenterologist who performs this examination can take biopsies of the esophagus to look for the precancerous cells. The cells, once examined by a pathologist, can determine if Barrett’s esophagus is present and if there is the presence of dysplasia. Dysplasia is the appearance of the cells that look even more abnormal and  more cancer like and can be classified as low and high grade. If no dysplasia is present on the biopsies, the treatment includes treatment of the GERD with PPI medications and surveillance EGD every 2-3 years. If the GERD symptoms are severe and don’t respond to PPI  medications, sometimes referral for antireflux surgery is indicated. Research has failed to show that surgical treatment of GERD in a Barrett’s patient prevents the development of esophageal adenocarcinoma.

Once dysplasia is present, the game changes as this patient is at high risk to develop esophageal cancer. These patients are followed more aggressively with more frequent EGD, multiple biopsies to determine if the dysplasia is low grade, high grade or signs of carcinoma in situ.
Treatments of dysplasia have changed in the last few years. The use of radiofrequency ablation, the “HALO” procedure, has been FDA approved for the treatment of Barrett’s with dysplasia. An EGD is performed and an electrode is passed through the scope to ablate the  Barrett’s tissue. Frequent endoscopy, retreatment with the device and aggressive treatment of GERD is recommended to attempt to prevent adenocarcinoma. If it is determined on biopsy that a small cancer, carcinoma in situ, is present, an endoscopic ultrasound may be  recommended to determine the depth of the cancerous cells into the wall of the esophagus which determines further treatments.

WHAT IF CANCER IS PRESENT?

Treatment of adenocarcinoma of the esophagus is difficult. Combinations of radiation therapy, chemotherapy and surgery for removal of some or the entire esophagus are may be indicated. This aggressive treatment has been shown to improve quality and length of life in  patients with esophageal cancer.

In summary, Heartburn and GERD are common. If you have frequent heartburn, talk to your doctor to see if referral to a gastroenterologist is warranted to determine if Barrett’s esophagus is present. It may save your life.

For more information, please contact Dr Liberski at sliberski@comcast.net.