Download Barrett`s Oesophagus

Barrett’s Oesophagus
Dr Simon Moodie
Barrett's oesophagus (Barrett's) is an abnormal lining of the oesophagus (otherwise
known as the gullet), which occurs in patients with a long history of heartburn and
reflux (acid and bile moving into the gullet). In a minority of people, Barrett's
oesophagus may progress through a series of stages (dysplasia) to cancer.
It is likely you have had reflux of stomach juices (acid, bile, enzymes) into your lower
oesophagus for some time. This may have caused symptoms such as heartburn or
indigestion. There will have been on going inflammation in your lower oesophagus
because of your reflux and your body has “coped” with this by changing the nature of
the cells that line the lower oesophagus. These have changed from the acid sensitive
oesophageal cells to intestine type cells. This area of intestinal type cells is seen on
the pictures below. This is called Barrett’s oesophagus. Barrett’s oesophagus is a risk
factor for developing oesophageal cancer.
How common is Barrett’s oesophagus?
Studies suggest that a 1cm or more Barrett’s segment occurs in:
Aproximately 8% of UK and USA adult population undergoing endoscopy.
Aproximately 3% of UK and USA adult population.
What is the risk of oesophageal cancer in Barrett’s?
Risk is a hard thing to describe in a way that gives a reasonable perspective –here are
the numbers from a recent (2016) review: annual risk of cancer for long (>3cm), short
(1-3cm) and ultrashort (<1cm) Barrett’s segments are 0.22%, 0.03%, 0.01%
respectively. This means if in one year 3440 patients with short segment Barrett’s
have a surveillance endoscopy we would expect to find just one cancer. This is a very
low risk indeed. The figure would be 450 for long segment Barrett’s. To put it another
way, the risk of cancer is less than one in 400 a year for long segment and less than 1
in 3000 per year for short segment, less than 1 in 12,000 per year for ultrashort
segment.
How can the risk of cancer be lowered?
Regular surveillance endoscopies probably lower the risk of dying from cancer by
enabling your doctor to both diagnose pre-cancerous changes developing and also to
diagnose very early cancers developing before they have caused any symptoms. This
allows a better chance of the cancer being curable by surgery plus possible
chemotherapy or radiotherapy. If precancerous changes are picked up at an endoscopy
this may be “low grade dysplasia” or “high grade dysplasia”. Low grade dysplasia can
sometimes be treated with ablation therapy to cauterize the whole segment of
Barrett’s and allow more normal oesophageal cells to grow back. This treatment is
relatively new, it can reduce risk of oesophageal cancer and is available on the NHS
(via referral to specialist centres). High grade dysplasia is such a high risk that
sometimes we suggest surgery (ranging from removal of small patches at endoscopy
to major surgery to remove segment of oesophagus)
What is the treatment of barrett’s oesophagus?
Most patients have associated symptoms of reflux disease and/or oesophagitis
(inflammation of the oesophagus) found at endoscopy. These patients clearly need
long term treatment with drugs to lower acid levels (usually a proton pump inhibitor
such as omeprazole or lansoprazole). This will not only improve symptoms but it is
thought that it may reduce oesophageal cancer risk although this has not been
conclusively proven. In patients with no symptoms and no oesophageal inflammation
most gastroenterologists also recommend long term proton pump inhibitor treatment
on the assumption that this will lower cancer risk, but again this is not completely
proven and it is reasonable in this group of patients to sometimes be on no regular
treatment if the patient has difficulty with the medication.
What tablets can I not take?
If you are on low dose aspirin, there is no reason to stop this unless you have had
ulcers or bleeding into your gut. Indeed, it is possible that aspirin may help in
Barrett’s but we do not yet know. Some medication may worsen reflux such as
calcium antagonists (diltiazem, amlodipine) and some other drugs for high blood
pressure and angina, also some oeteoporosis once a week drugs. It will be a question
of weighing up the benefits of these drugs with the risks.
Can I have an operation to treat my Barrett’s?
No. There are anti-reflux operations available for gastro-oesophageal reflux disease to
tighten the lower oesophageal sphincter. These are successful in some patients in
reducing their need for long term medication for their reflux. Anti-reflux operations
will not treat the Barrett’s but a few patients may opt for surgery to treat reflux
symptoms. There is at present no convincing evidence that these operations can
reduce risk of dysplasia or cancer in Barrett’s oesophagus. Endoscopic ablation can
reduce cancer risk in low and high grade dysplasia (see above). In high grade
dysplasia more radical surgery to remove the lower oesophagus is sometimes
recommended.
Summary
The vast majority of people with Barrett’s oesophagus will never develop
oesophageal cancer, but they are at a greater risk than the general population. We
currently recommend intermittent endoscopies and regular acid suppressing drugs for
most patients.