Barrett’s Esophagus (Intestinal Metaplasia)

What is Barrett's Esophagus?
Barrett's esophagus is a pre-cancerous condition of the lining of the esophagus, the muscular tube that carries foods, liquids and saliva from the mouth to the stomach. Barrett's esophagus is caused by the long-term exposure of the esophagus to acid reflux, a medical condition also known as GERD (gastroesophageal reflux disease).

1. Intestinal metaplasia (IM) - The tissue cells have begun to change genetically and the tissue resembles the red intestinal lining rather than the normal and healthy pink esophagus lining. At this stage, a person has Barrett’s esophagus, but has not developed Dysplasia, the next stage. (Risk of developing cancer 1-3%)

2. Low-grade Dysplasia (LGD IM) – Less than 50% of the abnormal cells have begun to change in size, shape, or organization and may show an increase in their growth rate. The cells are contained within the lining of the esophagus and have not spread to other areas. (Risk of developing cancer 10%)

3. High-grade Dysplasia (HGD IM) – As with LGD, the abnormal cells reside within the lining of the esophagus. But more than 50% of these cells do demonstrate a higher increase in abnormal growth rate and pattern. (Risk of developing cancer 50%)

4. Adenocarcinoma (Esophageal Cancer): When the abnormal cells have a rapid and uncontrolled growth rate. The cells also invade the deeper layers of your esophagus and may spread beyond that. These cells can develop into malignant tumors.
Adenocarcinoma can also be classified in different stages or categories. Contact your physician for more information.

Facts about Barrett's Esophagus:

• Barrett's esophagus prevalence is estimated to affect between 2 and 7 million adults over 40 years of age in the United States.
• Patients with Barrett's Esophagus are 30-125 times more likely to develop adenocarcinoma (esophageal cancer) than the general population.
• The incidence of esophageal adenocarcinoma has risen approximately six-fold in the U.S. It is rising faster than breast cancer, prostate cancer, or melanoma.
• Approximately 13% of Caucasian men over the age of 50, who have chronic reflux, will develop Barrett's esophagus.
• In a study conducted by the Veteran Affairs and Stanford University in Palo Alto, CA; 25% of patients > 50 years old without GERD symptoms were found to have Barrett's esophagus.
• Each year ~ 86,000 new cases of Barrett's esophagus are diagnosed.
• The incidence of Barrett's esophagus rises six-fold over the age of 50.
• Every year, approximately 14,550 people in the U.S. are diagnosed with esophageal cancer.
• Even with aggressive therapy, the 5-year survival rate from adenocarcinoma is only approximately 16%.
• Approximately up to 13% of Caucasian men over the age of 50, who have chronic reflux, will develop Barrett's esophagus.
• It's currently not possible on the basis of clinical presentation to distinguish GERD patients with Barrett's esophagus from those in whom Barrett's esophagus is not present
• GERD is common in the U.S. adult population. Symptoms of GERD, including heartburn, occur almost monthly in 50% of U.S. adults and weekly in almost 20%. 15
  

Treatment

Surveillance

One option for patients with Barrett's and no dysplasia or low-grade dysplasia is to have endoscopy (scopes with biopsy) periodically to try to identify patients who are progressing to cancer prior to the development of cancer. For patients with no dysplasia, the following chart demonstrates how often patients with no dysplasia will progress to more serious forms of Barrett's.

Progression of Intestinal Metaplasia to Low-Grade Dysplasia, High-Grade Dysplasia and Cancer

Data obtained from P. Sharma, et al. Dysplasia and Cancer in a Large Multicenter Cohort of Patients with Barrett's Esophagus. Clinical Gastroenterology and Hepatology. 2006; 4: 566-572.

This approach is not appropriate for patients with High Grade dysplasia as 50% of these patients will go on to develop cancer. Further the cure rate once cancer develops is less then 20%!

Ablation

Ablation therapy involves removing or destroying the abnormal Barrett's cells. There are several types of ablation treatments including: Endoscopic mucosal resection (EMR), Thermal Ablation (Argon plasma coagulation,Multi-polar coagulation,Bipolar energy,Lasers: Argon, Nd: YAG, KTP-YAG), Photodynamic Therapy.

A newer form of ablation therapy that has very encouraging results is the Barrx procedure using radiofrequency energy to ablate the Barrett's tissue. This is Dr. Fusco's recommended ablative procedure.