Barrett’s Esophagus

Barrett esophagus occurs when the squamocolumnar junction is displaced proximal to the gastroesophageal junction and the squamous lining of the lower esophagus is replaced by metaplastic columnar epithelium, which predisposes to the development of esophageal adenocarcinoma.

CAUSES

_ Metaplasia is thought to result from reepithelialization of esophageal tissue injured as a result of chronic GERD.

_ Patients with Barrett esophagus tend to have more severe esophageal motility disturbances (decreased lower esophageal sphincter pressure, ineffective peristalsis) and greater esophageal acid exposure on 24-hour pH monitoring.

_ Intraesophageal bile reflux may also play a role in the pathogenesis.

_ Familial clustering of GERD and Barrett esophagus suggests a genetic predisposition, but no gene has yet been identified.

_ Progression from metaplasia to carcinoma is associated with changes in gene structure and expression, including the caudal-related homeobox family of transcription factors (CDX1 and CDX2) and the tumor suppressors p16 (CDKN2A) and TP53.

SYMPTOMS

• Chronic heartburn
• Dysphagia with solid food
• May be an incidental finding on EGD in patients without reflux symptoms
• Less frequent: chest pain, hematemesis, melena
• Patients may be asymptomatic

PHYSICAL FINDING

• Nonspecific; can be completely normal
• Epigastric tenderness on palpation

DIFFERENTIAL DIANGOSIS

• GERD, uncomplicated
• Erosive esophagitis
• Gastritis
• Peptic ulcer disease
• Angina
• Malignancy

WORKUP

• The Practice Parameters Committee of the American College of Gastroenterology (ACG) has suggested that the highest yield for Barrett esophagus screening is in older (age >50 yr) white men with longstanding heartburn.
• EGD with biopsy is necessary for diagnosis.
• Wireless esophageal capsule endoscopy.

MANAGEMENT

_ Proton pump inhibitors are the most effective treatment for GERD. Therapy should be dosed to control symptoms and/or to promote healing of endoscopic signs of disease.

_ If patient is asymptomatic and incidentally found to have Barrett esophagus, proton pump inhibitors may still be considered, as they may reduce the risk of neoplastic progression.

_ CONSULT WITH YOUR DOCTOR.