HemeOnc
Barrett Esophagus
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Barrett Esophagus
, Barrett's Esophagus, Barrett's Metaplasia
See Also
Gastroesophageal Reflux
Disease
Esophageal Adenocarcinoma
Epidemiology
Prevalence
: 1.2 to 1.6%
Pathophysiology
Metaplasia
Columnar metaplasia of distal esophagus (from normal squamous cell lining)
Response to chronic inflammation from gastric acidic fluid via lower esophageal sphincter
Gastroesophageal Reflux
Precancerous lesion
Metaplasia progresses to
Esophageal Adenocarcinoma
in <0.33% of patients with Barrett Esophagus annually
Risk Factors
Precautions
Two or more positive risk factors significantly increase Barrett Esophagus risk
Gastroesophageal Reflux
GERD
Symptoms
Chronic
GERD
symptoms progresses to Barrett Esophagus in up to 10% of patients
Reported symptoms > 3x/week for 20 years: RR = 40
Self report weekly symptoms for prior year: OR = 29.7
GERD
duration
Persisted >10 years:
Odds Ratio
6.4
Persisted 5-10 years:
Odds Ratio
5.0
Persisted 1-5 years:
Odds Ratio
3.0
Increases risk of long-segment Barrett Esophagus
However, overall only a small percentage of those with
GERD
develop Barrett Esophagus
Up to half of patients in some studies are asymptomatic of Barrett Esophagus
Sharma (2009) N Engl J Med 361(26): 2548-56 [PubMed]
Caucasian (as opposed to asian, hispanic and black patients)
Hiatal Hernia
Age over 40-50 years old
Age >40 (OR=4.9)
Risk is even greater at age > 50 years old
Tobacco Abuse
Two fold increase in
Esophageal Cancer
with a 30 or 45 pack year history of
Tobacco Abuse
Odds Ratio
2.4 (former or current
Tobacco Abuse
)
Odds Ratio
51.4 if patient with
Tobacco Abuse
self-reports weekly
Acid Reflux
symptoms
Male gender
Odds Ratio
3.7
Obesity
(BMI >30 kg/m2)
Odds Ratio
n 4.0 regardless of symptoms
Odds Ratio
34.4 if obese patient self-reports weekly
Acid Reflux
symptoms
Evaluation
Endoscopy
Indications for screening for Barrett's Esophagus
Significant risk factors above
Red flag symptoms
Dysphagia
Odynaphagia or obstruction
Upper Gastrointestinal Bleeding
or
Anemia
Weight loss
Symptoms refractory to
Proton Pump Inhibitor
s
Surveillance and management protocol (controversial)
Guidelines are per American College of Gastroenterology
Overall correlate with American Society of Gastrointestinal Endoscopy, American College of Physicians, American Gastroenterological Association
GERD
Consider screening only once in patients with
GERD
with multiple risk factors or refractory to standard management (unless findings change)
GERD
without risk factors does not require upper endoscopy
Barrett's Esophagus without dysplasia
Repeat endoscopy with biopsy in one year
If no dysplasia x2 biopsies, then endoscopy every 3-5 years
Low grade dysplasia
Repeat endoscopy with biopsy in 6 months
Then repeat upper endoscopy annually until no dysplasia on 2 biopsies (and then endoscopy every 3 years)
High grade dysplasia
Repeat upper endoscopy every 3 months
Consider esophagectomy if able to undergo surgery
Consider endoscopic resection and ablation if not able to undergo surgery
References
Wang (2008) Am J Gastroenterol 103(3): 788-97 [PubMed]
Findings consistent with Barrett's Esophagus
Z-line is squamocolumnar junction
Z-Line is normally at gastroesophageal junction
Barrett's Esophagus
Z-line shifts up from gastroesophageal junction
Long-segment Barrett's: >3 cm from junction
Short-segment Barrett's: <3 cm from junction
Screening difficulties
Esophageal Cancer
is uncommon, even in Barrett's
Most
Esophageal Cancer
patients have no
GERD
symptoms
Longterm surveillance is still recommended
References
Gopal (2002) Evid Based Oncol 3(4):144-5 [PubMed]
Hage (2004) Scand J Gastroenterol 39:1175-9 [PubMed]
Management
Proton Pump Inhibitor
(e.g.
Prilosec
,
Protonix
) Long-term
High grade dysplasia
Noninvasive methods
Photodynamic therapy
Systemic
Photosensitizer
s administered followed by endoscopic exposure to laser light
Complete response in >78% of cases
Only treatment that significantly reduces Barrett Esophagus progression to cancer
Risk of
Esophageal Stricture
in 33%
Radiofrequency Ablation
Balloon placed adjacent to mucosal lesions and providers localized thermal ablation
Complete response in >91% of cases
Risk of
Esophageal Stricture
<8%
Endoscopic mucosal resection
Complete response in >76% of cases
Preferred method for endoscopic cancer staging
Risk of
Esophageal Stricture
in >50% (as well as bleeding and perforation)
Invasive methods
Esophagectomy
Prognosis
Endoscopy factors predicting low risk of adenocarcinoma
Low grade or no dysplasia on initial endoscopy and
Barrett's Esophagus length <6 cm
Weston (2004) Am J Gastroenterol 99:1657-66 [PubMed]
Complications
Barrett's Esophagus progression to
Esophageal Adenocarcinoma
Metaplasia progresses to
Esophageal Adenocarcinoma
in <0.5% of patients with Barrett Esophagus annually
Relative Risk
of adenocarcinoma with Barrett Esophagus: 11.3
Risk increases with longer segment Barrett Esophagus (1.1 RR/cm over 2 cm)
Long segment nondysplastic Barrett Esophagus: 0.33% cancer
Incidence
per year
Short segment nondysplastic Barrett Esophagus: 0.19% cancer
Incidence
per year
Risk increases with dysplasia on biopsy
No dysplasia: 1 case per 1000 patient-years
Low grade dysplasia: 5 cases per 1000 patient-years
High grade dysplasia: 42 cases per 1000 patient-years
Other factors with increased risk
Duration of symptoms >10 years
Esophagitis on upper endoscopy
References
Kahrilas in Feldman (2002) Sleisenger GI, p. 615-8
Katzka (2003) Hematol Oncol Clin North Am 17(2):471 [PubMed]
Sharma (2009) N Engl J Med 361(26): 2548-56 [PubMed]
Smith (2005) Cancer Epidemiol Biomarkers Prev 14(11 pt 1): 2481-6 +PMID:16284367 [PubMed]
Spechler (2002) N Engl J Med 346:836-42 [PubMed]
Zimmerman (2014) Am Fam Physician 89(2): 92-8 [PubMed]
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