The name may not be familiar to you, but thousands of Americans are
diagnosed each year with Barrett's Esophagus, a precancerous condition
often associated with severe heartburn. If you have been told you have
Barrett's Esophagus, this brochure may help answer some of your
questions. If you have additional questions, ask your doctor.
What Is Barrett's Esophagus?
To help digest food, the stomach produces large amounts of
hydrochloric acid every day. This powerful acid can liquefy a piece of
meat in a short time, but amazingly does not damage the stomach itself.
This is because the stomach has a special lining to protect itself from
the effects of the acid. However, the esophagus, or food pipe, has no
protective lining. Instead, there is a one-way "check valve" located at the
bottom of the esophagus that normally prevents backflow of stomach acid.
Called the Lower Esophageal Sphincter, this valve opens to allow food to
enter the stomach and then quickly closes to prevent the corrosive
stomach acid from damaging your delicate esophageal lining. If this
valve gets weak, however, acid from the stomach is allowed to come up
into the esophagus causing red erosions, like scrapes on the skin, on
the normally pinkish lining of the esophagus. This condition is called
Gastroesophageal Reflux Disease, or GERD. If the condition is not
properly treated, the erosions will continue and over time a permanent
red lining may develop. The cells in this lining resemble those of the
small intestine more closely than the normal esophagus, and are termed
"intestinal metaplasia." This is the hallmark of Barrett's Esophagus -
named after British surgeon, Norman Barrett, who first identified this
ailment in 1950. So, Barrett's is a condition where the pink lining of
the lower esophagus is damaged by years of uncontrolled
acid reflux and then the damaged area is replaced by a new abnormal red
lining which "creeps up" into the lower esophagus.
How Common Is Barrett's Esophagus?
Twenty percent or more of adults have chronic GERD and of these 10% to
15% will have Barrett's Esophagus, meaning that 1% to 2% of the American
adult population potentially has this premalignant condition. Men and
women with chronic severe reflux have over a 50% chance of having
Why Is Barrett's Important?
Overall, only about 0.5% per year of individuals with Barrett's Esophagus will
go on to develop esophageal cancer, but this rate is 40 times higher than
normal. Considered an oddity until the 1970's, the incidence of esophageal
cancer has increased rapidly in the past 30 years and is now the fastest rising
cancer in adults. Esophageal cancer seems to affect men much more than women.
What Are The Symptoms?
There really are no symptoms of Barrett's itself, but most patients have
a history of long standing acid reflux and complain of heartburn or
indigestion, occurring at least two times a week. Other symptoms may
include: difficulty swallowing food, waking up at night because of
heartburn pains, persistent unexplained cough, or hoarseness. If you
have these symptoms, you should be checked for Barrett's. Unfortunately,
some patients with Barrett's have very little heartburn and no warning,
even though they have significant damage.
How Does My Doctor Know?
Barrett's cannot be diagnosed by blood tests or x-rays. Screening
for Barrett's Esophagus requires a gastroscopy, or "scope" examination to
directly visualize the lower esophagus and determine if there is any
damage. This is painlessly done under light sedation. During this exam,
samples can also be taken to confirm the presence of Barrett's and to
check for precancerous changes, or dysplasia.
Why Bother Checking For Barrett's?
Anytime a cell line changes in the body, there is the potential for
cancerous changes. The challenge is to identify patients with Barrett's
Esophagus before they develop cancer. If you have Barrett's and biopsies
show precancerous cells, new techniques are available to monitor and
help halt the process. Progression to cancer can often be prevented.
However, it's estimated that only 5 percent of people with Barrett's are now
What Treatment Is Available?
Once Barrett's Esophagus is identified, doctors have several treatment
options available. The first goal is to stop acid reflux and prevent
further damage from occurring. This can usually be accomplished with
daily doses of medications such as Prilosec, Prevacid, Aciphex,
Protonix, and Nexium which markedly reduce your production of stomach
acid. Treatment relieves symptoms and may also reduce the risk of
forming a stricture, a ring of scar tissue which may cause problems
You should know that successful treatment of the acid reflux does not
cure the Barrett's. Even if symptoms are well controlled, the cancer
risk remains and periodic scope examinations must be continued. Usually
these are done every one to two years.
What If Dysplasia Is Found?
Biopsies taken during the scope test are sent for microscopic analysis
by a trained doctor called a Pathologist. The main thing we ask the
Pathologist to look for is "dysplasia." Dysplasia is a precancerous
change (not cancer yet) which usually occurs before cancer ever
develops. It can be thought of as an early warning signal and is often
classified either as low grade or high grade dysplasia.
Low grade dysplasia is seen most often and is less cause for concern. In
this instance, reflux must be controlled and surveillance may need to be
more frequent but there is no need for radical change in therapy. Over
time, dysplasia may progress from low grade to high grade,
then sometimes to cancer.
If high grade dysplasia is found, the risk of cancer is much greater.
Patients with high grade dysplasia need to be rescoped at more frequent
intervals and additional biopsies obtained. If high grade dysplasia
persists, there is a high risk of progression to cancer. In this
circumstance, more aggressive treatment is needed. This involves
surgery to remove part of the esophagus which contains the abnormal area
of Barrett's, even if a definite cancer is not found. The whole idea is
to do something before cancer develops.
How About Surgery?
There are two types of surgery performed in cases of Barrett's. If no
dysplasia is present and symptoms of acid reflux do not respond to
intensive medical therapy, surgery may be necessary to retighten the
loosened lower esophageal sphincter, thus preventing further acid
damage. This operation does not remove the area of Barrett's which still
must be periodically rebiopsied. In the past, this procedure required
open surgery with a full incision and a prolonged recovery period. Newer
"band-aid" techniques now allow a much simpler procedure with several
mini-incisions and a shortened recovery period.
If the condition is identified at a later stage, patients may require
surgery to actually remove part of the esophagus and pull the
stomach upward to the remaining portion. This is a more radical
operation, but totally removes the area of Barrett's.
Are There Any Alternatives?
- Photodynamic Therapy (PDT)
In this procedure, special light-activated dyes are given by vein which
makes the area of Barrett's especially sensitive to laser light. This
allows selective destruction of the area of Barrett's lining without
damaging the entire wall of the esophagus. The area becomes ulcerated
and is treated with medication. In most cases, when the ulcer heals, it
is replaced by the normal pale esophagus lining and not the abnormal
- Thermal Ablative Therapy
Other forms of ablation are being studied. One which holds promise is
the use of a heater probe. This device is passed down through the center
channel of a gastroscope. The tip has a computer controlled heating
device that "cooks" the tissue it contacts. This device has been used
for many years in the treatment of bleeding ulcers and is now being
tested in patients with Barrett's. One great concern with these new
destructive techniques is that not all of the Barrett's cells will be
destroyed and some may hide under the newly formed lining with a
potential for future cancer. Surveillance should be continued after treatment.
- Endoscopic Mucosal Resection (EMR)
Another new procedure might be useful when the Barrett's changes only
involve a short segment (less than 2 cm). Using the gastroscope and a
suction device, the inner layer of a portion of the esophagus is cut
away. This may allow normal cells to replace the Barrett's tissue. Early
reports are encouraging.
This refers to the exciting possibility that some medications taken by mouth may
reduce the chances of Barrett's cells becoming dysplastic and developing into
esophageal cancer. This research is very preliminary, but suggests that a daily
25,000 unit dose of the vitamin beta-carotene may be helpful. This dose is
considered safe for long term use. In addition, animal studies suggest that
aspirin and other arthritis drugs such as Clinoril, Vioxx, and Celebrex may
offer some protection. For example, in one study the risk of cancer was reduced
79% by Clinoril administration. All of these drugs can sometimes cause stomach
ulcers, but these are effectively prevented by the acid reducing medication that
is already being prescribed. This research is very exciting and suggests that
chemoprevention may be a useful treatment option for the prevention of cancer.
Barrett's Esophagus is a precancerous condition in which an abnormal
lining grows up into the lower esophagus. This is usually a consequence
of long-standing poorly controlled acid reflux. Barrett's tissue does not
belong there and for some reason increases the risk of cancer. Most
often, the development of this type of cancer is preceded by findings of
dysplasia on biopsy. Currently, screening by
periodic "scope" examinations is the only available way to determine if dysplasia is present.
If you have Barrett's Esophagus, you will require periodic monitoring by
your physician. Follow your doctor's advice about how best to control
your acid reflux. This may include lifestyle changes, medication, and/or
surgery. The goal should be complete control of heartburn. Keep your
appointments for regular endoscopy exams and biopsies to check for
Be reassured that most patients with Barrett's do not go on to develop
cancer of the esophagus. The overall risk is low. By working with your doctor and having periodic examinations, you can best control the symptoms of acid reflux and help reduce your personal risk of esophageal cancer.
[ Revised 11/2003 ]