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Heartburn Heartburn Basics

Barrett's Esophagus: How Reflux Can Turn Into Cancer

Are there any symptoms of Barrett's esophagus?
The unfortunate part of the process is that the symptom presentation is no different than someone with simple reflux disease. In fact, the Barrett's tissue itself is, to some degree, less acid-sensitive. So, one of the reasons we see people who develop cancer from Barrett's late in the disease is that the symptoms are milder because the tissue doesn't sense acid as easily.

If the tissue doesn't sense acid, does that make people think their condition is getting better?
Yes. One of things that I try to teach my trainees is that if, in the course of following someone, a patient talks about their heartburn decreasing in frequency, they should be concerned that either Barrett's had developed or that some other complication had occurred. Typically, reflux doesn't spontaneously go away.

How is a diagnosis of Barrett's esophagus made?
If a gastroenterologist decides to look for Barrett's, the only effective screening modality is an endoscopy. And the endoscopist is looking for is a change in the appearance of the esophageal mucosa, or lining, to look like the tissue found in the stomach.

Are there any treatments for Barrett's esophagus?
The guidelines that we follow are that patients with Barrett's are treated similar to patients with reflux disease; we make every effort to make them symptom-free.

There is no evidence that higher doses of medication will actually cause a reduction in Barrett's tissue. Surgery also hasn't been proven to decrease the risk of cancer. So my bias is, if you had Barrett's, I would offer you aggressive treatment for reflux. That is, I would make sure that your acid was controlled, and then I would tell you what other treatments were possible to consider and let you make your own choice.

How often would a patient with Barrett's be screened for esophageal cancer?
What we try to do is a systematic biopsy soon after diagnosis. There, we take extensive tissue samples to determine whether someone has any cellular changes, called dysplasia, which is the first step in a cell becoming cancerous.

We then do two endoscopies, approximately a year apart. After that, if there is no dysplasia or abnormality beyond the Barrett's, then the patient at this point would have endoscopy every two or three years. Now, if you have dysplasia or abnormal cells, I think it's sufficient to say that you should be surveyed more frequently to be ahead of the game, so to speak, if the dysplasia is going to progress.

Are there any additional treatments if dysplasia is found?
At that point, it is important for the physician to have another discussion with the patient about investigational therapies. And I say "investigational" because we have the capability of removing this tissue using either thermal therapy, laser therapy and now we even have the capability to endoscopically remove tissue.

The problem is that it is hard to prove that you can remove all the tissue. Since even a little bit could be bad, we've kind of hesitated to make a blanket recommendation that if you have dysplasia you should attempt to have it removed. But it's an important discussion to have with patients because, as you can guess, people don't like to sit there with it.

Does someone with minor reflux need to be worried about getting Barrett's?
One of the overall problems with reflux is that people don't stop refluxing simply because they're on a drug like Nexium or Prevacid. Even with these drugs, they're still refluxing material that is not as damaging, so they aren't getting symptoms. And even with surgery you don't completely eliminate reflux.

I think anyone who has a long-term need to take medication for heartburn or who is given a diagnosis of reflux would do well to consult a care provider to understand what their risks are.

Certainly, if you are in the typical Barrett's age group—over the age of 50—and you have an endoscopy that does not show any Barrett's, I would be very comfortable telling you that you didn't need another screening.

What advice do you have for someone with reflux disease?
Anyone with reflux disease should learn about Barrett's so that they can be informed as to their potential risk. This is an evolving field, and we're learning enough about the disease that going forward, our technologies are going to evolve to a point where if we can make an impact in treating Barrett's esophagus, it's going to be early on in the disease.

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