Barrett Esophagus

Snapshot

• A 50-year-old woman complains of increased regurgitation, especially when lying down. Her father had esophageal cancer at a young age, and she is worried about also having it. She is slightly overweight and has had GERD for the past 3 years. While her PCP makes a note in her file, she reassures the patient that she does meet the requirements for routine screening for esophageal cancer, but the physician will keep an eye out on her GERD. In the meantime, the physician prescribes a proton-pump inhibitor for daily use.

Introduction

• Metaplastic transformation of esophageal lining 
  • normal squamous epithelium →
  • → columnar epithelium 
  • → intestinal metaplasia (with globlet cells)
• Result of chronic gastroesophageal reflux disease (GERD) 
• Pathogenesis
  • mucosal injury causes acute and chronic inflammatory change
  • esophageal stem cells develop columnar intestinal metaplasia
• Risk factors
  • GERD > 5-10 years
  • age > 50 years
  • male  > female
  • obesity
• Associated conditions
• risk of progression to adenocarcinoma

Presentation

• Symptoms
  • heartburn
  • regurgitation
• Physical exam
• typically normal

Evaluation

• Diagnosis with upper endoscopy with biopsy showing both 
  • histology 
    • metaplastic columnar epithelium with goblet cells (normally in stomach and intestines) in esophageal mucosa
• visualization of abnormal distal esophageal mucosa 

Differential Diagnosis

• Erosive esophagitis
• Gastritis

Treatment

• Lifestyle modifications
  • weight loss
  • elevate head of bed
• Proton pump inhibitor for GERD
• Regular endoscopic surveillance to monitor risk of dysplasia and carcinoma

Prognosis, Prevention, and Complications

• Prognosis
  • ↑ lifetime risk of esophageal cancer
    • 5% in men
    • 3% in women
  • ↑ annual risk of esophageal cancer in Barrett esophagus
    • 0.5% – 2.8% per year
• Complications
  • progression to adenocarcinoma
  • ulceration leading to stricture formation