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What is Barrett's Oesophagus?
Barrett's oesophagus is a complication of GORD. It is a permanent change in the lining of the gullet to resemble that of the stomach, intestine or colon. Not everyone who has acid reflux will develop Barrett's oesophagus. Up to 1 in 10 (10%) of people with acid reflux will go on to develop it. This is more likely to happen in people who have had severe reflux symptoms for many years, in men and in people over 50.
A small number of people will experience changes in the cells of the oesophagus. These changes in the cells are sometimes called dysplasia. They are pre-cancerous changes. Dysplasia can be either low-grade, or high-grade depending upon how abnormal the changes are, with high grade being the most abnormal.
What is Barrett's Oesophagus?
The oesophagus (gullet) is the tube that carries food from the mouth to the stomach and is lined by cells similar to those that form the skin (squamous cells). In Barrett's Oesophagus the lining at the lower end of the gullet is found to have changed from being skin-like to being like the lining of the stomach, intestine or colon. It was first identified in the early 1950's by a surgeon called Norman Barrett, but the other name is columnar-lined oesophagus (CLO). There are various types of Barrett's oesophagus (or CLO) called body metaplasia (resembling stomach), junctional metaplasia (resembling colon) and intestinal metaplasia (resembling intestine or colon).
Barrett's oesophagus occurs when the normal cells that line the lower part of the oesophagus (squamous cells) are replaced by a different cell type (resembling stomach, colon or intestinal cells). This process usually results from repetitive damage by acid to the oesophageal lining. The most common cause of this is long standing gastro-oesophageal reflux disease (GORD), a condition in which the oesophagus is exposed to excessive amounts of stomach acid, bile acid or pancreatic juice. Interestingly, the intestinal cells of Barrett's oesophagus are more resistant to acid than squamous cells, suggesting that they may be an adaptation to the chronic acid or bile and acid exposure. The problem with this adaptation is that the intestinal cells have a small potential to transform into cancer cells. This lifetime risk is 5% (1:20 chance) for men and 3% (1:30 chance) for women. If cancer does develop it is usually in people over 70 years of age.
Risk Factors
Research has identified a number of risk factors associated with Barrett's oesophagus:
Age
Barrett's Oesophagus is most commonly diagnosed in middle aged and older adults: the average age at diagnosis is 55 years. Children can develop Barrett's oesophagus, bur rarely before the age of 5 years. Cancer does not develop until at least 15-20 years of acid exposure.
Gender
Men are more commonly diagnosed with Barrett's oesophagus than women.
Ethnic background
Barrett's oesophagus is equally common in white and Hispanic populations and is uncommon in black and Asian populations.
Lifestyle
Smokers are more commonly diagnosed with Barrett's oesophagus than non smokers. Heavy alcohol in excess of 21 units of alcohol can also aggravate reflux. Behaviours that can worsen reflux include eating meals just prior to going to bed, lying down after eating meals, and eating very large meals.
Obesity
People who are moderately (BMI>30) or severely (BMI>40) overweight are x5 and x40 more likely respectively to develop Barrett's metaplasia and oesophageal cancer.
Diet
The first priority in treating Barrett's oesophagus is to stop the ongoing damage of the oesophageal lining, which usually means eliminating acid reflux. Most patients are advised to avoid certain foods and behaviours that increase the risk of reflux. Foods that can worsen reflux include:
ChocolateCoffee and TeaPeppermintFatty foods
Acidic juices such as orange or tomato may also worsen symptoms. Carbonated beverages can be a problem for some people.
Sleep
Placing bricks or blocks under the head of the bed (to raise it by about six inches) help to keep acid in the stomach while sleeping. This works well for patients who have severe night time reflux but is does require the patience of their partners.
Diagnosis
A healthcare provider may suspect Barrett's oesophagus based upon a patient's symptoms and the risk factors described above, but an Endoscopy, almost always with an endoscopic biopsy, is needed to confirm the presence of an abnormal oesophageal lining.
Upper endoscopy
During this procedure, a thin lighted tube is passed into the oesophagus after the patient is sedated. The lining normally appears pale and glossy, while the lining of a person with Barrett's appears pink or red and velvet like. A biopsy is usually performed during the endoscopy so that the lining can be examined.
Endoscopic Biopsies
Small tissue samples are taken from your gullet during endoscopy. The usual number is 4-20.
What are the symptoms?
Symptoms can be broken into three general groups: typical of reflux, atypical of reflux but consistent with its action once other causes are excluded and alarm symptoms that should necessitate immediate referral to hospital. In should also be noted that Barrett's oesophagus itself often produces no symptoms. Some people have no symptoms at all and the Barrett's oesophagus is discovered during tests for other medical conditions.
Typical symptoms
Most patients with this condition seek help because of GORD, including heartburn (a dull discomfort behind the sternal bone), regurgitation of stomach contents, and, less commonly, a salty taste in the back of the mouth called water brash.
Atypical symptoms
These include hoarseness; some people have pain when swallowing food, chest pain, asthma and even bloating.
Alarm symptoms
These include:
difficulty in swallowing (dysphagia),vomiting of blood,unintentional weight loss, andanorexia (loss of appetite).
If you experience any of these problems for more than two weeks (or have a single episode of vomiting blood) it is advisable to visit your GP.
What are the complications of Barrett's?
Barrett's Oesophagus can lead to complications such as ulcers in the gullet, bleeding, difficulty in swallowing due to narrowing of the gullet (stricture), ulceration of the gullet and occasionally cancer. The majority of people who have Barrett's Oesophagus have no serious consequences (90%). Only a minority will develop any of the above complications (10%).
What exactly happens during endoscopy?
Your GP will examine you and may refer you to the hospital for a procedure known as an endoscopy to examine the lining of your oesophagus. The endoscopy may be carried out by a doctor or specialist nurse, and enables the oesophagus to be examined using a thin flexible tube called an endoscope. Usually small samples of cells (biopsies) are taken, which can then be examined in a laboratory to see if they are normal.
You can usually have an endoscopy as an outpatient, but occasionally an overnight stay in hospital is necessary. You will be comfortably positioned on a couch. You may be given the choice of having a local anaesthetic spray to numb the back of your throat (and reduce any discomfort during the test); or a sedative to make you feel sleepy. The sedative is usually injected into a vein in the arm. The doctor or nurse then passes the endoscope down your oesophagus. 80% of return Barrett's patients prefer throat spray alone as it allows a quicker recovery
An endoscopy can be uncomfortable but is not painful. After a few hours the effect of the sedative or anaesthetic will wear off and you'll be able to go home. If you receive a sedative injection, you shouldn't drive for 24 hours after the test and, if possible, you should arrange for someone to travel home with you. The nurse or doctor will tell you how long to wait before you try to swallow anything. It may be around 1-2 hours afterwards. Some people have a sore throat following the procedure; this is normal and usually disappears after a couple of days. If it does not, it is advisable to contact your doctor at the hospital. You should also tell your doctor if you have any chest pain, breathlessness or blood in your vomit.
Endoscopic Surveillance
Often, people with Barrett's oesophagus are advised to have their condition checked at regular intervals in order to pick up any further changes. This is known as surveillance and usually involves regular endoscopies and biopsies. At present, it is not known how useful surveillance is. This is because of the small number of people with Barrett's oesophagus who actually go on to develop oesophageal cancer. It will be some time before the benefits and the possible disadvantages of regular endoscopies become clear.
Depending on the degree of change in your condition, if any, and the policy at your hospital, the endoscopies may be repeated at intervals between 3 months and 2 years.
A clinician may prescribe medications that suppress the stomach's acid production and decrease reflux into the oesophagus. A class of medications called proton pump inhibitors are most commonly used to treat reflux in patients with Barrett's.
Newer treatments being investigated
Ways of removing just the abnormal cells from the lining of the oesophagus are being studied. For example, by using lasers during endoscopy it may be possible to "burn off" the abnormal cells. A recent refinement of this is called photodynamic therapy.
Photodynamic therapy (PDT) is a type of laser treatment. For this you are given a drug that makes your cells very sensitive to light for several hours. After being given the drug you have an endoscopy a laser light is shone at the abnormal section of your oesophagus. The cells which are sensitised by the drug react to the laser light and the cells are destroyed. Nearby normal cells then multiply and replace the destroyed abnormal cells.
There are possible side effects from PDT which include narrowing of the oesophagus (called a stricture) which may affect swallowing. Also, some people may develop skin reactions because of the drug that is given. At present photodynamic therapy is at the experimental stage. Research is still ongoing to asses exactly how well it works in the long term.
Another new treatment that is being investigated is using radiofrequency energy coil to treat Barrett's oesophagus. Again, this involves an endoscopy. During the endoscopy, a small coil is guided towards the abnormal section of your oesophagus. The idea is that the coil emits the heat energy that destroys the abnormal cells. Nearby normal cells then multiply and replace the destroyed abnormal cells. Again, this procedure is being investigated in trials and exactly how well it works in the long-term is uncertain.
If you are diagnosed with Barrett's oesophagus, your specialist should be able to give you up-to-date information on the pros and cons of surveillance, and the current situation about newer treatments such as PDT.
Endoscopic Resection (also called endoscopic mucosal resection) is becoming widely accepted for dysplasia and even early oesophageal cancer in many centres. This technique is done during endoscopy and a small abnormal area of the gullet lining is lassoed and burnt off.
All these techniques have a certain complication rate with serious adverse events ranging from 3-25%.
Large trials investigating prevention methods
AspECT has recruited 2513 patients and aims to see if low dose aspirin and acid suppression therapy can decrease cancer risk for patients with Barrett's this trial is closed to recruitment and patients are in follow up.
BOSS is recruiting 2500 patients and aims to see how good Barrett's surveillance is at catching early cancers in Barrett's. This trial is open to everyone all patients are encouraged to enrol via their local specialist. No extra visits needed.
ChoPIN is recruiting 5000 patients and already 2500 have been enrolled. This trial aims to assess the genetic predisposition (risk) of Barrett's patients in developing complications. This trial is open to recruitment and all patients are encouraged to enrol via their specialist. One blood sample needed only.
HANDEL This trial aims to assess the genetic risk of families for Barrett's as well as those with oesophageal adenocarcarnoma. This trial is open to recruitment and all patients are encouraged to enrol via their specialist. One blood sample needed only.
Other Websites:
? www.nice.org.uk - Dyspepsia Guidelines, Barrett's Ablation Therapy Guidelines
Picture sourced from ? www.refluxhelp.org
Information gathered from
? www.patient.co.uk
? www.macmillan.org.uk
? www.corecharity.org.uk
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