Barrett Esophagus

Aka: Barrett Esophagus, Barrett's Esophagus, Barrett's Metaplasia

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II. Epidemiology

  1. Prevalence: 1.2 to 1.6%

III. Pathophysiology

  1. Metaplasia
    1. Columnar metaplasia of distal esophagus (from normal squamous cell lining)
  2. Response to chronic inflammation from gastric acidic fluid via lower esophageal sphincter
    1. Gastroesophageal Reflux
  3. Precancerous lesion
    1. Metaplasia progresses to Esophageal Adenocarcinoma in <0.33% of patients with Barrett Esophagus annually

IV. Risk Factors

  1. Precautions
    1. Two or more positive risk factors significantly increase Barrett Esophagus risk
  2. Gastroesophageal Reflux
    1. GERD Symptoms
      1. Chronic GERD symptoms progresses to Barrett Esophagus in up to 10% of patients
      2. Reported symptoms > 3x/week for 20 years: RR = 40
      3. Self report weekly symptoms for prior year: OR = 29.7
    2. GERD duration
      1. Persisted >10 years: Odds Ratio 6.4
      2. Persisted 5-10 years: Odds Ratio 5.0
      3. Persisted 1-5 years: Odds Ratio 3.0
    3. Increases risk of long-segment Barrett Esophagus
    4. However, overall only a small percentage of those with GERD develop Barrett Esophagus
    5. Up to half of patients in some studies are asymptomatic of Barrett Esophagus
      1. Sharma (2009) N Engl J Med 361(26): 2548-56 [PubMed]
  3. Caucasian (as opposed to asian, hispanic and black patients)
  4. Hiatal Hernia
  5. Age over 40-50 years old
    1. Age >40 (OR=4.9)
    2. Risk is even greater at age > 50 years old
  6. Tobacco Abuse
    1. Two fold increase in Esophageal Cancer with a 30 or 45 pack year history of Tobacco Abuse
    2. Odds Ratio 2.4 (former or current Tobacco Abuse)
    3. Odds Ratio 51.4 if patient with Tobacco Abuse self-reports weekly Acid Reflux symptoms
  7. Male gender
    1. Odds Ratio 3.7
  8. Obesity (BMI >30 kg/m2)
    1. Odds Ration 4.0 regardless of symptoms
    2. Odds Ratio 34.4 if obese patient self-reports weekly Acid Reflux symptoms

V. Evaluation: Endoscopy

  1. Indications for screening for Barrett's Esophagus
    1. Significant risk factors above
    2. Red flag symptoms
      1. Dysphagia
      2. Odynaphagia or obstruction
      3. Upper Gastrointestinal Bleeding or Anemia
      4. Weight loss
      5. Symptoms refractory to Proton Pump Inhibitors
  2. Surveillance and management protocol (controversial)
    1. Guidelines are per American College of Gastroenterology
      1. Overall correlate with American Society of Gastrointestinal Endoscopy, American College of Physicians, American Gastroenterological Association
    2. GERD
      1. Consider screening only once in patients with GERD with multiple risk factors or refractory to standard management (unless findings change)
      2. GERD without risk factors does not require upper endoscopy
    3. Barrett's Esophagus without dysplasia
      1. Repeat endoscopy with biopsy in one year
      2. If no dysplasia x2 biopsies, then endoscopy every 3-5 years
    4. Low grade dysplasia
      1. Repeat endoscopy with biopsy in 6 months
      2. Then repeat upper endoscopy annually until no dysplasia on 2 biopsies (and then endoscopy every 3 years)
    5. High grade dysplasia
      1. Repeat upper endoscopy every 3 months
      2. Consider esophagectomy if able to undergo surgery
      3. Consider endoscopic resection and ablation if not able to undergo surgery
    6. References
      1. Wang (2008) Am J Gastroenterol 103(3): 788-97 [PubMed]
  3. Findings consistent with Barrett's Esophagus
    1. Z-line is squamocolumnar junction
      1. Z-Line is normally at gastroesophageal junction
    2. Barrett's Esophagus
      1. Z-line shifts up from gastroesophageal junction
      2. Long-segment Barrett's: >3 cm from junction
      3. Short-segment Barrett's: <3 cm from junction
  4. Screening difficulties
    1. Esophageal Cancer is uncommon, even in Barrett's
    2. Most Esophageal Cancer patients have no GERD symptoms
    3. Longterm surveillance is still recommended
    4. References
      1. Gopal (2002) Evid Based Oncol 3(4):144-5 [PubMed]
      2. Hage (2004) Scand J Gastroenterol 39:1175-9 [PubMed]

VI. Management

  1. Proton Pump Inhibitor (e.g. Prilosec, Protonix) Long-term
  2. High grade dysplasia
    1. Noninvasive methods
      1. Photodynamic therapy
        1. Systemic Photosensitizers administered followed by endoscopic exposure to laser light
        2. Complete response in >78% of cases
        3. Only treatment that significantly reduces Barrett Esophagus progression to cancer
        4. Risk of Esophageal Stricture in 33%
      2. Radiofrequency Ablation
        1. Balloon placed adjacent to mucosal lesions and providers localized thermal ablation
        2. Complete response in >91% of cases
        3. Risk of Esophageal Stricture <8%
      3. Endoscopic mucosal resection
        1. Complete response in >76% of cases
        2. Preferred method for endoscopic cancer staging
        3. Risk of Esophageal Stricture in >50% (as well as bleeding and perforation)
    2. Invasive methods
      1. Esophagectomy

VII. Prognosis: Endoscopy factors predicting low risk of adenocarcinoma

  1. Low grade or no dysplasia on initial endoscopy and
  2. Barrett's Esophagus length <6 cm
  3. Weston (2004) Am J Gastroenterol 99:1657-66 [PubMed]

VIII. Complications: Barrett's Esophagus progression to Esophageal Adenocarcinoma

  1. Metaplasia progresses to Esophageal Adenocarcinoma in <0.5% of patients with Barrett Esophagus annually
  2. Relative Risk of adenocarcinoma with Barrett Esophagus: 11.3
  3. Risk increases with longer segment Barrett Esophagus (1.1 RR/cm over 2 cm)
    1. Long segment nondysplastic Barrett Esophagus: 0.33% cancer Incidence per year
    2. Short segment nondysplastic Barrett Esophagus: 0.19% cancer Incidence per year
  4. Risk increases with dysplasia on biopsy
    1. No dysplasia: 1 case per 1000 patient-years
    2. Low grade dysplasia: 5 cases per 1000 patient-years
    3. High grade dysplasia: 42 cases per 1000 patient-years
  5. Other factors with increased risk
    1. Duration of symptoms >10 years
    2. Esophagitis on upper endoscopy

IX. References

  1. Kahrilas in Feldman (2002) Sleisenger GI, p. 615-8
  2. Katzka (2003) Hematol Oncol Clin North Am 17(2):471 [PubMed]
  3. Sharma (2009) N Engl J Med 361(26): 2548-56 [PubMed]
  4. Smith (2005) Cancer Epidemiol Biomarkers Prev 14(11 pt 1): 2481-6 +PMID:16284367 [PubMed]
  5. Spechler (2002) N Engl J Med 346:836-42 [PubMed]
  6. Zimmerman (2014) Am Fam Physician 89(2): 92-8 [PubMed]

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Ontology: Barrett Esophagus (C0004763)

Definition (NCI_NCI-GLOSS) A condition in which the cells lining the lower part of the esophagus have changed or been replaced with abnormal cells that could lead to cancer of the esophagus. The backing up of stomach contents (reflux) may irritate the esophagus and, over time, cause Barrett's esophagus.
Definition (NCI) Esophageal lesion lined with columnar metaplastic epithelium which is flat or villiform. Barrett epithelium is characterized by two different types of cells: goblet cells and columnar cells. The symptomatology of Barrett esophagus is that of gastro-esophageal reflux. It is the precursor of most esophageal adenocarcinomas. (WHO)
Definition (MSH) A condition with damage to the lining of the lower ESOPHAGUS resulting from chronic acid reflux (ESOPHAGITIS, REFLUX). Through the process of metaplasia, the squamous cells are replaced by a columnar epithelium with cells resembling those of the INTESTINE or the salmon-pink mucosa of the STOMACH. Barrett's columnar epithelium is a marker for severe reflux and precursor to ADENOCARCINOMA of the esophagus.
Definition (CSP) syndrome including peptic ulcer of the lower esophagus, often with stricture, due to the presence of columnar lined epithelium, which may contain functional mucous cells, parietal cells, or chief cells in the esophagus instead of normal squamous cell epithelium; sometimes pre-malignant, followed by esophageal adenocarcinoma.
Concepts Disease or Syndrome (T047)
MSH D001471
ICD9 530.85
ICD10 K22.7 , K22.70
SnomedCT 235597001, 196609006, 302914006, 76355008, 155679007, 196603007
LNC LA14288-7
English Esophagus, Barrett, Syndrome, Barrett's, CELLO - Col epith-lin low oeso, CLE - Columnar-lined oeso, Columnar epith-lined low oeso, BO - Barrett's esophagus, Barrett's Esophagus, Barretts Esophagus, Esophagus, Barrett's, Barrett Syndrome, Barrett's Syndrome, Barretts Syndrome, Syndrome, Barrett, Barrett's esophagus (diagnosis), Barrett's oesophagitis, Barrett esophagus, Barrett Esophagus [Disease/Finding], barrett's esophagitis, barrett's esophagus, barretts syndrome, barrett's oesophagitis, barrett's oesophagus, barrett esophagus, barrett's syndrome, barrett syndrome, barrett oesophagitis, barrett esophagitis, Barretts syndrome, Barrett's esophagus NOS, Barrett's disease, Endobrachyoesophagus, BARRETT ESOPHAGUS, BARRETT METAPLASIA, Barretts esophagus, Barrett's esophagitis, Barrett Metaplasia, Barrett's oesophagus (disorder), Endobrachyooesophagus, Columnar-lined esophagus, Barrett's esophagus, Barrett's syndrome, Gastric metaplasia of esophagus, Barrett's oesophagus, Columnar-lined oesophagus, Gastric metaplasia of oesophagus, BO - Barrett's oesophagus, CELLO - Columnar epithelial-lined lower esophagus, CELLO - Columnar epithelial-lined lower oesophagus, CLE - Columnar-lined esophagus, CLE - Columnar-lined oesophagus, Columnar epithelial-lined lower esophagus, Columnar epithelial-lined lower oesophagus, Barrett's esophagus (disorder), Barrett, Barrett's esophagus (disorder) [Ambiguous], Barrett Esophagus, BE, Columnar Epithelial-Lined Lower Esophagus, Columnar-Lined Esophagus, CELLO, CLE, Esophagitis;Barretts, Oesophagitis;Barretts, Barretts esophagitis, Barretts oesophagitis
Dutch Barret-oesophagus, endobrachyoesophagus, Barrett-oesophagitis, Barrett-oesofagitis, Barrett-oesophagus, Barrett-oesofagus, Barrett-syndroom, Oesofagus, Barrett-
French Oesophagite de Barrett, EBO (EndoBrachyOesophage), Endobrachyoesophage, Oesophage de Barrett, Syndrome de Barrett
German Barrett-Oesophagitis, Endobrachyoesophagus, Barrett-Ulkus, Barrett-Syndrom, Barrett-Ösophagus, Ösophagus, Barrett-
Italian Endobrachiesofago, Esofagite di Barrett, Sindrome di Barrett, Esofago di Barrett
Portuguese Endobraquiesófago, Esofagite de Barrett, Esófago de Barrett, Esôfago de Barrett, Síndrome de Barrett
Spanish Endobraquioesófago, Esofagitis de Barrett, síndrome de Barret, epitelio cilíndrico en el esófago distal, esófago distal revestido con epitelio cilíndrico, esófago con epitelio columnar, síndrome de Barrett, metaplasia gástrica de esófago, epitelio columnar en el esófago distal, esófago de Barret (concepto no activo), esófago de Barret (trastorno), esófago de Barret, metaplasia gástrica del esófago, esófago de Barret [dup] (trastorno), Esófago de Barrett, Síndrome de Barrett
Japanese 食道円柱上皮化, ﾊﾞﾚｯﾄｼｮｸﾄﾞｳ, ｼｮｸﾄﾞｳｴﾝﾁｭｳｼﾞｮｳﾋｶ, Barrett食道, Barrett症候群, バレット食道, バレット症候群, 食道-バレット
Swedish Barretts esofagus
Finnish Barrettin ruokatorvi
Russian BARRETA PISHCHEVOD, PISHCHEVOD BARRETA, БАРРЕТА ПИЩЕВОД, ПИЩЕВОД БАРРЕТА
Czech Endobrachyezofagus, Barretův jícen, Barrettův jícen, Barrettův ezofágus, Barretova ezofagitida
Korean 바렛 식도
Polish Wrzód trawienny przełyku, Przełyk Barretta
Hungarian Barrett oesophagitis, Endobrachyoesophagus, Barrett-oesophagus, Barrett oesophagus, Barrett-oesophagitis
Norwegian Barretts syndrom, Barretts sykdom, Barretts øsofagus, Barretts oesophagus
Derived from the NIH UMLS (Unified Medical Language System)

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