Diseases

Barrett’s Esophagus


Barrett’s esophagus is a condition affecting the lining of the esophagus, the swallowing tube that carries foods and liquids from the mouth to the stomach. Barrett's esophagus was estimated to affect approximately 3.3 million adults over 50 years of age in the United States.  Men develop Barrett’s esophagus twice as often as women, and Caucasian men are affected more often than men of other races.  Barrett's esophagus is caused by injury to the esophagus from the chronic backwash of stomach contents (like acid and enzymes) that occurs with acid reflux. There are no symptoms specific to Barrett’s esophagus, other than the typical symptoms of acid reflux (or GERD).  Many people affected with Barrett’s esophagus never notice any symptoms such as heartburn.



In some people, the damage and inflammation associated with acid reflux can cause genetic changes that cause the normal esophagus tissue (pictured above left) to change into intestinal tissue (pictured above right).  When that happens, it is called Barrett’s esophagus. It is estimated that 13% of the people who have chronic acid reflux (GERD) also have Barrett’s esophagus, but many people can have Barrett’s esophagus without symptoms of chronic acid reflux (GERD) like heartburn.  Barrett’s esophagus can only be diagnosed with an upper endoscopy (EGD).  While the average age at diagnosis of Barrett’s esophagus is 50, it is difficult to determine when the disease developed and thus, how long a patient has been affected.

Who is at Risk?
Those at risk for developing Barrett’s esophagus include those people who are in any one of the following categories:

  • Over 50 years of age
  • Males
  • Individuals of Caucasian or White race
  • Suffer from chronic GERD (heartburn)
  • Obese
  • Have increased intra-abdominal fat distribution

Cancer Risk
People with Barrett's esophagus are 30 to 125 times more likely to develop cancer of the esophagus than the general population. The incidence of esophagus cancer has risen about six-fold in the U.S. since the 1970s. It is rising faster than breast cancer, prostate cancer, or melanoma. If you have frequent or long-standing acid reflux symptoms, you should consult a physician. Left untreated, chronic acid reflux (GERD) can lead to the development of pre-cancerous cells. In a small percentage of patients, that can result in a life-threatening cancer of the esophagus. 

Cancer occurs when the abnormal cells involved in Barrett's esophagus have rapid and uncontrolled growth and invade the deeper layers of your esophagus. This is called cancer of the esophagus, or esophageal adenocarcinoma (EAC). The cancer can also spread beyond the esophagus.

Patients with the first phase of Barrett’s esophagus (intestinal metaplasia) have a combined risk of 1.4% per year of progressing to high-grade dysplasia or cancer (“dysplasia” refers to abnormalities of a tissue or cell that make it more cancer-like and disorganized). While rare, cancer of the esophagus is the most rapidly rising cancer in the U.S. It is often incurable because it is frequently discovered at a late stage.

Surveillance
After you have a diagnosis of Barrett's esophagus, endoscopy with biopsy (examination of your esophagus and sampling of the tissue) at various intervals to detect progression to more severe stages of disease or cancer. The frequency at which you undergo surveillance may be dependent upon the stage (severity) of your Barrett's esophagus.

Surgical Removal of the Esophagus
Once Barrett's esophagus progresses to cancer, removal of the esophagus may be necessary to avoid cancer related death. Called an esophagectomy, this surgery involves removing the esophagus and top part of the stomach.  A portion of the stomach is then pulled up into the chest and connected to the remaining normal portion of the esophagus or pharynx, creating a "new" esophagus. Because this is a major operation, there are significant risks.

Historically, surgery has been used for certain non-cancer stages of Barrett's esophagus (high-grade dysplasia) in an effort to avoid operating on more advanced cancer stages of this disease. However, in the last 5 years most high-grade dysplasia patients and even early cancer patients are treated with endoscopic therapy, such as BARRX-HALO, rather than surgery.

BARRX-HALO (Radiofrequency Ablation)
Radiofrequency ablation (BARRX-HALO) uses an electrode mounted either on a balloon or endoscope to deliver heat energy to the diseased lining of the esophagus. A number of studies have demonstrated that BARRX-HALO safely results in a high rate of complete eradication of Barrett's esophagus, as well as reduces progression of the disease to high-grade dysplasia and cancer.  Because of a favorable safety profile, studies have been performed assessing the efficacy of RFA for the earliest stages of Barrett's, as well as later stages.

Regional Surgicenter was the first ambulatory surgery center in the U.S., and the only center in the Quad-Cities area, to offer the full line of BARRX-HALO radiofrequency ablation techniques.  The physicians at Gastroenterology Consultants perform radiofrequency ablation procedures on a regular basis. 

BARRX-HALO is done in a similar fashion to an upper endoscopy (EGD).  While you are sedated, a device is inserted through the mouth into the esophagus and used to deliver a controlled level of energy and power to remove a thin layer of diseased tissue. Less than one second of energy removes tissue to a depth of about one millimeter. The ability to provide a controlled amount of heat to diseased tissue is one mechanism by which this therapy has a lower rate of complications than other forms of ablation therapy.

Larger areas of Barrett’s tissue are treated with the balloon-mounted catheter. Smaller areas are treated with the endoscope-mounted catheter. Both are introduced during an upper endoscopy procedure, which is a thin, flexible tube inserted through a patient’s mouth.

Radiofrequency ablation for Barrett's esophagus has been used in more than 60,000 cases and the devices are cleared by the U.S. Food and Drug Administration. The balloon-based catheter has been available commercially since January 2005, the endoscope-mounted catheter since January 2007.

A recent clinical trial showed that 98.4% of people were free of Barrett’s at a follow-up exam 30 months after two or three RFA treatments.  Studies show that when the Barrett’s tissue is removed, it is typically replaced by normal, healthy tissue within three to four weeks. Recent five-year follow-up of longer-term trials show that the effects of radiofrequency ablation are durable.

After the procedure, you may notice some mild to moderate heartburn like discomfort, for which your physician will prescribe liquid pain medications.  A soft diet is recommended for the first week after each session. 

A minimum of three sessions is required and sometimes more sessions of BARRX-HALO are required to obtain full results.  Radiofrequency ablation does not replace or remove the need for routine surveillance upper endoscopy (EGD) with biopsy.

Endoscopic Mucosal Resection (EMR)
For areas within the Barrett's esophagus lining which are raised or depressed, and thus suspicious for cancer, a method called endoscopic mucosal resection (EMR) is used to remove the damaged lining. Using a snare delivered through an endoscope, tissue can be removed to a depth of about 2 mm and then evaluated to diagnose the seriousness of the disease. The benefit of EMR is that large biopsy specimens can be removed to render the lining flat. The disadvantage is that use of EMR for wide spread Barrett's has an unacceptable complication rate. Therefore, focal EMR for specific areas of concern has been followed 2 months later by RFA to safely and effectively remove the remainder of the Barrett's esophagus.