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Barrett esophagus

Etiology: 1) chronic irritation of the distal esophagus from refluxed gastric acid & pepsin (GERD) 2) esophageal mucosal damage due to chemotherapy 3) associated with a) long-standing GERD b) large hiatal hernia c) low lower esophageal sphincter pressure d) esophageal dysmotility 4) risk factors - age > 50 years - Caucasian race - central obesity - smoking - family history [21] - chronic GERD (>= 5 years) Epidemiology: 1) occurs in 10% of patients with gastroesophageal reflux 2) overall prevalence 1.6% [6] 3) 2-fold greater prevalence in whites vs non-whites [9] 4) overdiagnosis in 1/3 of patients Pathology: 1) extension of the metaplastic columnar epithelium above the gastroesophageal junction into the esophagus 2) metaplasia of the squamous mucosa in the distal esophagus to a more resistant gastric type (columnar epithelium) 3) adenocarcinoma can arise from Barrett's esophagus - risk is 0.8%/year (a 30-50 fold increased risk) 4) low-grade dysplasia may regress [5] 5) acid facilitates expression of NOX5, associated with increased proliferation, reduced apoptosis Genetics: 1) 17p LOH (p53) predicts progression to adenocarcinoma [6] 2) implicated genes: NOX5 Clinical manifestations: 1) associated with gastroesophageal reflux 2) may occur in association with peptic ulcer disease 3) may be asymptomatic Special laboratory: - upper gastrointestinal endoscopy - proton pump inhibitor prior to endoscopy may improve accuracy of screening [7] - esophageal biopsy (endoscopic muscoal resection) - do not perform biopsy if Z line is normal or has < 1 cm of variability - obtain biopsy prior to endoscopic ablation [2] - use the Prague classification for reporting circumferential & maximal segment length. - if initial screening shows erosive esophagitis, repeat endoscopy after 8-12 weeks of proton-pump inhibitor [21] - appears as salmon-colored mucosa compared with the normal pink-colored squamous mucosa above the gastroesophageal junction. - MKSAP image may look more like blood than salmon [2] Radiology: - upper GI series may show stricture in the mid-esophagus Complications: - risk of progression: - increased with duration, dysplasia, male gender [26] - decreased by proton pump inhibitors, statins [26] - increased risk of esophageal carcinoma - HR = 11-30 [14]; 30-50 [2] - absolute risk is 0.12-0.22% per year [14,20] - risk is higher for those with dysplasia at initial biopsy (1.40% vs. 0.17% in those without dysplasia) - most esophageal cancer is diagnosed at the original endoscopy [23] - risk is high inpatients with intestinal metaplasia [11,14] (0.38% vs. 0.07%) - annual risk among US veterans is 0.32% [19] - 80-85% of esophageal adenocarcinoma detected within 1 year of Barrett esophagus diagnosis [25] - if H pylori infection, risk of esophageal carcinoma > gastric carcinoma [30] Management: 1) aggressive management of gastroesophageal reflux - proton pump inhibitor [2,18] - dosage based on symptom relief & healing of erosive esophagitis [2] - does not reduce progression to esophageal cancer [2] - NSAID use may lower risk for esophageal cancer, but does not reduce risk for Barrett esophagus [24] 2) endoscopic surveillance vs endoscopic ablation [2,18] a) dysplasia grade: none-indefinite 1] optimized medical therapy [2] 2] surveillance every 3-5 years [21] or sooner if indefinite [2] -involved segment: < 3 cm every 5 years, >= 3 cm every 3 years [2] 3] discontinue if life-expectany < 1 year or if patient unable to tolerate procedure 4] surveillance may be unnecessary [13] b) dysplasia grade: low 1] surveillance at 6 months & 1 year, then, yearly until age 80 2] radiofrequency ablation is preferable to surveillance if patient is amenable [28] 3] radiofrequency ablation slows progression of low-grade dysplasia [16] c) dysplasia grade: high - radiofrequency ablation rather than surveillance is indicated [16,28] - surveillance every 3 months for 2 years, then every 6 months (if patient refuses ablation) d) high grade dysplasia or adenocarcinoma [31] - endoscopic ablation for patients with high grade dysplasia [2] - combined muscosal resection with ablation of remaining Barrett esophagus is an option [2] - endoscopic ablation if intramucosal cancer [28] - esophagectomy for esophageal cancer if patient is a surgical candidate [2] 3) endocopic surveillance - associated with detection of earlier stage esophageal cancer & may provide a small survival benefit [27] - continue endoscopic surveillance after successful resection of lesions & radiofrequency ablation [28] 4) radiofrequency ablation or photodynamic therapy - endoscopic resection of all visible lesions prior toendoscopic ablation [28] - eradicates metaplasia in 75% ofpatients [2,10] 5) screening - do not routinely screen women with GERD [2,21] - screen men > 50 years with chronic GERD symptoms (> 5 years) & additional risk factors for Barrett esophagus or esophageal cancer [2] - nocturnal reflux, elevated BMI, tobacco use, abdominal fat Notes: - overdiagnosis in 1/3 of patients [17]

Related

esophageal cancer

General

esophagitis metaplasia

Database Correlations

OMIM 109350

References

  1. Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 280
  2. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 15, 16, 17, 18, 19. American College of Physicians, Philadelphia 1998, 2006, 2009, 2012, 2015, 2018, 2021. - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022 - Medical Knowledge Self Assessment Program (MKSAP) 20 American College of Physicians, Philadelphia 2025
  3. Harrison's Principles of Internal Medicine, 13th ed. Isselbacher et al (eds), McGraw-Hill Inc. NY, 1994, pg 1359
  4. Journal Watch 21(2):14, 2001 Macdonald CE et al Final results from 10 year cohort of patients undergoing surveillance for Barrett's oesophagus: observational study. BMJ 321:1252, 2000 PMID: 11082084 - McGarrity TJ Barrett's oesophagus: the continuing conundrum. BMJ 321:1238, 2000 PMID: 11082070
  5. Journal Watch 23(21):167, 2003 Conio M et al Long-term endoscopic surveillance of patients with Barrett's esophagus. Incidence of dysplasia and adenocarcinoma: a prospective study. Am J Gastroenterol 98:1931, 2003 PMID: 14499768 - Sampliner RE Long-term endoscopic surveillance of Barrett's esophagus. Am J Gastroenterol 98:1912, 2003 PMID: 14499764
  6. Ronkainen J et al, Prevalence of Barrett's esophagus in the general population: An endoscopic study. Gastroenterology 2005 129:1825 PMID: 16344051
  7. Hanna S et al, Detection of Barrett's esophagus after endoscopic healing of erosive esophagitis. Am J Gastroenterol 2006, 101:1416 PMID: 16863541
  8. P Sharma. Barrett's Esophagus: Diagnosis and Treatment http://www.medscape.com/viewarticle/463423 - Barrett's Esophagus https://www.niddk.nih.gov/health-information/digestive-diseases/barretts-esophagus
  9. Abrams JA et al, Racial and ethnic disparities in the prevalence of Barrett's esophagus among patients who undergo endoscopy. Clin Gastroenterol Hepatol 2008, 6:30 PMID: 18063419
  10. Shaheen NJ et al, Radiofrequency Ablation in Barrett's Esophagus with Dysplasia NEJM 2009, 360:2277-2288 PMID: 19474425 http://content.nejm.org/cgi/content/short/360/22/2277
  11. Bhat S et al Risk of Malignant Progression in Barrett's Esophagus Patients: Results from a Large Population-Based Study JNCI J Natl Cancer Inst (2011): June 16, 2011 PMID: 21680910 http://jnci.oxfordjournals.org/content/early/2011/06/16/jnci.djr203.abstract - Corley DA Understanding Cancer Incidence in Barrett's Esophagus: Light at the End of the Tunnel NCI J Natl Cancer Inst (2011): June 16, 2011 PMID: 21680911 http://jnci.oxfordjournals.org/content/early/2011/06/16/jnci.djr223.full
  12. Hvid-Jensen F et al Incidence of Adenocarcinoma among Patients with Barrett's Esophagus N Engl J Med 2011; 365:1375-1383October 13, 2011 PMID: 21995385 http://www.nejm.org/doi/full/10.1056/NEJMoa1103042
  13. Corley DA et al. Impact of endoscopic surveillance on mortality from Barrett's esophagus - associated esophageal adenocarcinomas. Gastroenterology 2013 Aug; 145:312. PMID: 23673354
  14. Wang KK, Sampliner RE; Practice Parameters Committee of the American College of Gastroenterology. Updated guidelines 2008 for the diagnosis, surveillance and therapy of Barrett's esophagus. Am J Gastroenterol. 2008 Mar;103(3):788-97 PMID: 18341497
  15. Shaheen NJ, Richter JE. Barrett's oesophagus. Lancet. 2009 Mar 7;373(9666):850-61 PMID: 19269522
  16. Elia J NEJM Journal Watch. March 14, 2014 Massachusetts Medical Society http://www.jwatch.org - Phoa KN et al Radiofrequency Ablation vs Endoscopic Surveillance for Patients With Barrett Esophagus and Low-Grade DysplasiaA Randomized Clinical Trial. JAMA. 2014;311(12):1209-1217 PMID: 24668102 http://jama.jamanetwork.com/article.aspx?articleid=1849991 - Monkemuller K Radiofrequency Ablation for Barrett Esophagus With Confirmed Low-Grade Dysplasia. JAMA. 2014;311(12):1205-1206 PMID: 24668100 http://jama.jamanetwork.com/article.aspx?articleid=1849966
  17. Ganz RA et al. Barrett's esophagus is frequently overdiagnosed in clinical practice: Results of the Barrett's Esophagus Endoscopic Revision (BEER) study. Gastrointest Endosc 2014 Apr; 79:565 PMID: 24262638
  18. Spechler SJ and Souza RF Barrett's Esophagus N Engl J Med 2014; 371:836-84. 5August 28, 2014 PMID: 25162890 http://www.nejm.org/doi/full/10.1056/NEJMra1314704
  19. Shakhatreh MH et al. The incidence of esophageal adenocarcinoma in a national veterans cohort with Barrett's esophagus. Am J Gastroenterol 2014 Dec; 109:1862 PMID: 25331350
  20. Kroep S et al. An accurate cancer incidence in Barrett's esophagus: A best estimate using published data and modeling. Gastroenterology 2015 Sep; 149:577 PMID: 25935635
  21. Shaheen NJ et al. ACG clinical guideline: Diagnosis and management of Barrett's esophagus. Am J Gastroenterol 2015 Nov 3; PMID: 26526079
  22. Spechler SJ, Sharma P, Souza RF et al American Gastroenterological Association technical review on the management of Barrett's esophagus. Gastroenterology. 2011 Mar;140(3):e18-52 PMID: 21376939 - Spechler SJ, Sharma P, Souza RF, Inadomi JM, Shaheen NJ. American Gastroenterological Association medical position statement on the management of Barrett's esophagus. Gastroenterology. 2011 Mar;140(3):1084-91 PMID: 21376940
  23. Visrodia K et al. Magnitude of missed esophageal adenocarcinoma after Barrett's esophagus diagnosis: A systematic review and meta-analysis. Gastroenterology 2016 Mar; 150:599 PMID: 26619962 http://www.gastrojournal.org/article/S0016-5085%2815%2901722-9/abstract
  24. Thrift AP et al. Nonsteroidal anti-inflammatory drug use is not associated with reduced risk of Barrett's esophagus. Am J Gastroenterol 2016 Aug 30 PMID: 27575711
  25. Visrodia K et al. Systematic review with meta-analysis: Prevalent vs. incident oesophageal adenocarcinoma and high-grade dysplasia in Barrett's oesophagus. Aliment Pharmacol Ther 2016 Oct; 44:775. PMID: 27562355
  26. Krishnamoorthi R, Singh S, Ragunathan K et al. Factors associated with progression of Barrett's esophagus: A systematic review and meta-analysis. Clin Gastroenterol Hepatol 2017 Nov 30 PMID: 29199147
  27. Codipilly DC, Chandar AK, Singh S et al. The effect of endoscopic surveillance in patients with Barrett's esophagus: A systematic review and meta-analysis. Gastroenterology 2018 Feb 17 PMID: 29458154 http://www.gastrojournal.org/article/S0016-5085(18)30225-7/pdf
  28. Standards of Practice Committee, Wani S, Qumseya B, Sultan S et al. Endoscopic eradication therapy for patients with Barrett's esophagus-associated dysplasia and intramucosal cancer. Gastrointest Endosc 2018 Apr; 87:907-931.e9. PMID: 29397943
  29. NEJM Knowledge+ Question of the Week. Dec 4, 2018 https://knowledgeplus.nejm.org/question-of-week/397/ - Shaheen NJ, Falk GW, Iyer PG et al. ACG clinical guideline: diagnosis and management of Barrett's esophagus. Am J Gastroenterol 2016 Jan; 111:30. PMID: 26526079
  30. NEJM Knowledge+ Gastroenterology - Spechler SJ, Souza RF. Barrett's esophagus. N Engl J Med. 2014 Aug 28;371(9):836-45. doi: 10.1056/NEJMra1314704. PMID: 25162890 Review. https://www.nejm.org/doi/pdf/10.1056/NEJMra1314704
  31. Sharma P, Shaheen NJ, Katzka D, et al. AGA clinical practice update on endoscopic treatment of Barrett's esophagus with dysplasia and/or early cancer: expert review. Gastroenterology. 2020;158:760-769. PMID: 31730766
  32. Shaheen NJ, Falk GW, Iyer PG et al Diagnosis and Management of Barrett's Esophagus: An Updated ACG Guideline. Am J Gastroenterol. 2022 Apr 1;117(4):559-587. PMID: 35354777 PMCID: PMC10259184 Free PMC article. https://pmc.ncbi.nlm.nih.gov/articles/PMC10259184/