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Related Subjects: |Achalasia |Oesophageal Carcinoma |Diffuse Oesophageal spasm |Diffuse Oesophageal Perforation - Rupture |Gastro-Oesophageal Reflux |Barrett's oesophagus

It is a premalignant condition in which the normal lining of the oesophagus is replaced with tissue that is similar to the lining of the intestine that may evolve into an adenocarcinoma due to chronic inflammation associated with GORD/GERD

Flat cells elongate
Reprogrammed, a change of fate
Acid splashes burn
Battered, scarred, loss of order
Scarlet tongues GE border
@DrCindyCooper

About

• Barrett’s oesophagus is defined as an oesophagus in which any portion of the normal distal squamous epithelial lining has been replaced by metaplastic columnar epithelium
• It is clearly visible endoscopically (=1 cm) above the GOJ and confirmed histopathologically from oesophageal biopsies

Aetiology

• Barrett's oesophagus is caused by Gastro- oesophageal reflux disease
• Metaplasia such that the normal squamous epithelium is replaced by tall glandular columnar cells
• Risks: Male gender, older age and history of reflux symptoms
• Ethnicity: Caucasians have a higher risk compared to other ethnic groups.
• Obesity: abdominal obesity promotes acid reflux.
• Smoking: increases the risk of Barrett's oesophagus.

Risk factors for malignancy

• GORD symptoms
• Male sex, Age over 45
• Length over 8 cm
• Early onset
• Ulceration or Stricture

Investigations

• Endoscopy: grey and pale normal squamous appearance is replaced by pink columnar epithelium
• Biopsy may be performed to confirm and look for dysplasia or carcinoma. Multiple biopsies are taken as dysplasia can be patchy. Biopsies are usually taken 2 cm apart. The biopsy may also reveal dysplasia, which is a precancerous change in the cells. Dysplasia is graded as: No dysplasia, Low-grade dysplasia, High-grade dysplasia. An Indocarmine spray can help spot dysplastic changes seen through the endoscope

Management

• Dietary Changes to reduce GORD. Reduce spicy foods, citrus, caffeine, and alcohol. Reducing weight, especially abdominal fat, can decrease reflux. Elevating the Head of the Bed: This helps prevent nighttime reflux. Quit Smoking: Smoking cessation is critical
• Proton Pump Inhibitors (PPIs): reduce acid production. Long-term use is often necessary. H2-Receptor Antagonists: can also reduce stomach acid, though they are generally less effective than PPIs.
• Regular endoscopies are recommended to monitor for dysplasia or early signs of oesophageal cancer. The frequency of surveillance depends on the presence and grade of dysplasia.
• Endoscopic Treatments: Radiofrequency Ablation (RFA): This procedure uses heat to destroy abnormal cells in the oesophagus, which can help reduce the risk of progression to cancer. Endoscopic Mucosal Resection (EMR): Used to remove larger areas of abnormal tissue or early-stage cancer. Cryotherapy: Another option where abnormal tissue is destroyed by freezing.
• Oesophagectomy: high-grade dysplasia or early oesophageal cancer, surgical removal of part or all of the oesophagus may be necessary. Major procedure with significant risks.

Screening: NICE

• Offer high resolution white light endoscopic surveillance with Seattle protocol biopsies:
  • every 2 to 3 years to people with long-segment (3 cm or longer) Barrett's oesophagus
  • every 3 to 5 years to people with short-segment (less than 3 cm) Barrett's oesophagus with intestinal metaplasia.
• Assess a person's risk of cancer based on their age, sex, family history of oesophageal cancer and smoking history and tailor the frequency of endoscopic surveillance accordingly, within the intervals given in recommendation
• Do not offer endoscopic surveillance to people with short-segment (less than 3 cm) Barrett's oesophagus without intestinal metaplasia provided the diagnosis has been confirmed at 2 endoscopies.
• Traditional treatment is with high dose Proton pump inhibitors though there is no real evidence that they make much difference
• Patients with a diagnosis of indefinite for dysplasia should be managed with an optimisation of the Anti reflux medical therapy and re-endoscoped in 6 months. If no definite dysplasia is found on subsequent biopsies, then the surveillance strategy should follow the recommendation for non-dysplastic Barrett’s oesophagus
• Oesophagectomy in some cases. See algorithm below.

References

• British Society of Gastroenterology guidelines on the diagnosis and management of Barrett’s oesophagus