Everything you’ve ever wanted to know about Barrett’s esophagus

We are having a baby girl! (1)

Okay, so, when I first started this shindig, I had this ambitious goal of writing a medical GI-themed post every Friday, something important but funny for the public.  I even had a cute name for the endeavor: “Farting Fridays.”  You know, because GI, and because there is an alliteration, and people love alliterations on the internet.  However, I have found that as usual, life foils my plans: kids and things, and work, and charting (oh, god, charting) take up way too much of my time, plus who can think of a weekly topic that would actually interest people?  I mean, poop and butts proved very popular, but how much can I really write about poop, realistically? So, here I am writing a GI post on a Saturday, and maybe I’ll call it “Shitting Saturdays” or something less obscene but also with an alliteration.

But anyway, a few weeks ago, I did come out with a very informative article (if I do say so myself) about acid reflux.  As a follow up to that, I am now going to address Barrett’s esophagus.  Try to hold back the excitement, folks.

First things first.  Let’s recap:

  • It’s not acid reflex, it’s acid reflux
    • ReFLUX – the flowing back of a liquid, especially that of a fluid in the body
    • ReFLEX – an action that is performed as a response to a stimulus and without conscious thoughtHiatal_Hernia

Next, let me warn you that if you say “HIGH ANAL HERNIA,” I will probably laugh at you; I will not be able to keep a straight face.  I realize that’s unprofessional, but it’s also very funny because anuses will never cease to be funny.

  • High anal hernia – is not a thing. If it were, it would involve something about your anus, which is at the opposite end of acid reflux
  • It’s HIATAL hernia, which refers to a part of the stomach sneaking up into the chest from the abdomen through the hiatus (a little hole) in the diaphragm

 

Now that this is out of the way, let’s discuss Barrett’s.

What is Barrett’s?

It is a pre-cancerous condition of the food pipe (esophagus).  The normal lining of the esophagus is flat, shiny, and light pink.  In Barrett’s esophagus, the lining changes over to a different type, a glandular type, which is only supposed to be present in the intestine.

Why do we care about this?

I refer you to sentence #1 in the previous paragraph.  It is a pre-cancerous condition.  That means there is a chance that it might develop into cancer.  The vast majority of this type of esophageal cancer (adenocarcinoma) arises from Barrett’s esophagus.  The actual chance of malignant conversion is something like 0.5% per year, but if you figure that the average person gets diagnosed with Barrett’s around middle age and has 30-40 more years to live, taken all together, that is a decent chance of developing cancer.

barrett's
I did not draw this. I got this from this website: http://bme240.eng.uci.edu/students/07s/jpuckett/page_215.htm

What?! Why?!

The classic teaching is that people with Barrett’s have a history of long-standing acid reflux, which is when gastric contents splash up into the esophagus.  This causes chronic inflammation in the esophageal lining.  With time, chronic inflammation causes changes in the DNA make up of these cells, and with each turnover of cells, they become more and more abnormal.  However, some people are found to have Barrett’s and have never experienced acid reflux.  There is some talk of “silent” reflux, but this really has not been proven.

I’m getting worried.  Who gets this?

The text-book contingent is an overweight white man of middle age who has chronic reflux and currently smokes or has smoked in the past.  However, anyone can get it.

Wait, I’m a white male, somewhat overweight… How do I know if I have it?

You may not know.  Barrett’s in and of itself does not have any symptoms.  If there are symptoms, they are usually related more to the reflux than to the actual Barrett’s esophagus.  There is some discussion whether off the cuff screening of supposed high risk individuals is necessary, but there is not enough data to support this – i.e. we don’t know if this will actually help anyone diagnose or treat or improve survival in esophageal cancer.  If you have had acid reflux or heartburn for more than a few years, and more than just occasionally, get thee to a doctor.

Maybe I will.  What will the doctor do?

The doctor will most likely recommend you have an endoscopy.  Barrett’s can be spotted because it looks different, and the doctor can biopsy it to confirm diagnosis.  If there is a long stretch, multiple biopsies might be necessary.

Is that the thing where they stick a tube down your throat? I gag easily.

Yes, it is the thing where we stick a tube down your throat.  It looks like this:

921px-Gastroscopy_by_Hecker
JUST KIDDING!

JUST KIDDING.  Don’t worry, we put you to sleep for the procedure.  You have to come in fasting (nothing to eat or drink after midnight) and have a ride home.  When you get to the appointment, they will put in an IV, and use sedatives to make you nice and sleepy so you don’t feel the tube or gag.  The tube is the size of an extra-large noodle, and is flexible and soft-ish.  The whole procedure takes 5-10 minutes, maybe 15, depending on what we find inside.

If I have it, can’t you cut it out so I don’t get cancer?

Not as such, no.  Barrett’s is managed by monitoring and surveillance.  Once diagnosed, you will undergo endoscopy with biopsy every 3-5 years.  We are looking for what’s called “dysplasia,” which refers to the progressive damage of the lining where the cells become more and more abnormal and start to exhibit bizarre behavior like reproducing in plain site of everyone on the surface (seriously! that’s called a “mitotic body” if you want to know).  You might hear the following terms:

  • Low-grade dysplasia, if cells show small signs of precancerous changes.
  • High-grade dysplasia,  dysplasia can get really disorganized and abnormal, and become invasive, meaning that it infiltrates down into deeper tissues – and that is cancer.

OMG.  How do I make sure I don’t get dysplasia?

The only thing we got is aggressive acid suppression therapy.  That means an acid lowering medication every day for ever.  Fortunately, these medications, usually a proton pump inhibitor like omeprazole, are tolerated very well.

Holy crap.  What if I do have “dysplasia?”

It can get a little hairy.  If the changes in the lining are small or not too advanced, the doctor may elect to treat the reflux aggressively as above, and repeat surveillance in a year or even 6 months.  If there are more advanced changes, then, even though we can’t cut it out per se, we will try to get rid of it in other ways.

  • Endoscopic resection, which uses an endoscope to remove damaged cells
    • this works if the badness is localized in a visible nodule or bump
  • Radiofrequency ablation, which uses heat to fry abnormal esophagus tissue. Radiofrequency ablation may be recommended after endoscopic resection
  • Cryotherapy, which uses cold to freeze the abnormal cells
  • Photodynamic therapy, which uses light to destroy the cells
  • Surgery , in which they remove a portion of your esophagus, and join up the rest with the stomach

The choice of therapy will depend on what your health status is otherwise, what your risk for surgery is, and which treatment is available in your area.  After treatment, you will need to continue to be monitored.

And that’s all I got, folks.  Bottom line is, it’s best not to be an overweight white middle aged male smoker, at least for Barrett’s purposes.  In other areas of life, I dare say, it might be nice to be a middle aged white male at least, even if not overweight or a smoker.

Don’t freak out and see a doctor if you have heartburn.  Good luck.

 

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