Barrett esophagus
Barrett esophagus is metaplasia of the distal esophageal squamous lining into intestinal columnar epithelium driven by chronic GERD, and it is the established precursor of esophageal adenocarcinoma. Diagnosis requires endoscopy showing salmon-colored mucosa above the gastroesophageal junction confirmed by biopsy showing intestinal metaplasia with goblet cells, and management, from surveillance interval to endoscopic ablation, is dictated entirely by the graded dysplasia.
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What this article covers
- Overview
Definition: replacement of the normal stratified squamous epithelium of the distal esophagus with metaplastic columnar epithelium containing specialized intestinal-type glands, occurring even without ongoing reflux symptoms.
- Epidemiology
Detection rate: about 10 percent of patients undergoing endoscopy for GERD are found to have Barrett esophagus.
- Risk factors
Chronic GERD: reflux symptoms for more than 5 years is the dominant risk factor and the basis for selective screening.
- Pathophysiology
Chronic acid and bile injury: long-standing reflux of gastric acid, and often bile, across an incompetent lower esophageal sphincter repeatedly injures the distal squamous mucosa.
- Clinical features
Usually asymptomatic from the metaplasia itself: produces no symptoms of its own; it is found incidentally during endoscopy performed for GERD or its complications.
- Differential diagnosis
Esophageal adenocarcinoma: progressive dysphagia and weight loss with a mass or ulcerated lesion on endoscopy, an advanced point on the same metaplasia-to-cancer continuum (esophageal cancer).
- Diagnosis
Confirmed by endoscopy with biopsy showing histologic change: the diagnosis requires an endoscopic finding of salmon-colored mucosa extending proximal to the gastroesophageal junction, replacing the…
- Management
Treat the underlying reflux in every patient regardless of dysplasia grade: start or continue a proton pump inhibitor, omeprazole 20 mg PO once daily 30 to 60 minutes before breakfast, continued…
- Complications
Progression to esophageal adenocarcinoma: the central concern, occurring through the stepwise dysplasia continuum, with risk rising from 0.2 to 0.5 percent per year (no dysplasia) to 7 percent per year (high-grade dysplasia).
- Prognosis
Dysplasia grade is the dominant prognostic factor: annual cancer risk scales directly with grade, from 0.2 to 0.5 percent per year with no dysplasia, to 0.7 percent per year with low-grade dysplasia…
- Prevention
Selective screening endoscopy for high-risk GERD patients: men older than 50 years with chronic GERD symptoms for more than 5 years plus at least one additional risk factor (nocturnal reflux, hiatal…
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Related articles
- Gastroesophageal reflux disease (GERD)
GERD is retrograde reflux of gastric contents into the esophagus causing heartburn and regurgitation, diagnosed clinically and confirmed by response to an empiric PPI trial, with endoscopy reserved for alarm features or refractory symptoms. Management proceeds from lifestyle measures through an 8-week once-daily PPI trial, dose escalation or agent switch for partial response, and fundoplication for medication-refractory or regurgitation-predominant disease.
- Esophageal cancer
Esophageal cancer comprises squamous cell carcinoma, driven by tobacco, alcohol, and caustic or motility injury to the upper and mid esophagus, and adenocarcinoma, arising from GERD-driven Barrett esophagus distally, both presenting with progressive dysphagia from solids to liquids plus weight loss. Diagnosis is by upper endoscopy with biopsy, staged with CT, PET, and endoscopic ultrasound, and treatment is stage-directed from endoscopic resection through esophagectomy with perioperative chemotherapy or chemoradiation to palliative chemoradiation and stenting.