BARRETT'S ESOPHAGUS

The esophagus is a long muscular tube connecting the mouth to the stomach. The esophagus acts to push swallowed food down into the stomach. At the lower end of the esophagus is a sphincter (a small band of muscle) that prevents the acid from the stomach from refluxing back into the esophagus. The lining of the esophagus is made of cells called squamous, or flat cells. In Barrett's esophagus, the squamous cells convert to another type of cell called columnar (long cells that look like columns). It is important to detect Barrett's esophagus because 5% to 10% of patients who have this disorder develop cancer of the esophagus.

The specific cause of Barrett's esophagus is not known; however, it is thought to originate from long-standing acid reflux disease. Barrett's esophagus can occur in 10% to 15% of patients that have acid reflux disease. Barrett's esophagus is not hereditary and is not transmitted from person to person. It is usually detected by upper endoscopy (a lighted tube that is placed into the mouth and down into the esophagus). During upper endoscopy, the esophagus can be examined and any suspicious areas can be biopsied (removing tissue with a needle and looking at it under a microscope). Once the diagnosis is made, the physician will make specific treatment and cancer screening recommendations.

Most symptoms from Barrett's esophagus are similar to symptoms found in patients who have acid reflux or acid indigestion. Heartburn is the characteristic symptom and usually occurs at nighttime, often waking the patient up from sleep. Other symptoms can include chest pain, difficulty swallowing, and food getting stuck or having to regurgitate the food back up. Shortness of breath, wheezing, laryngitis, and hoarseness can also occur.

The major complication from Barrett's esophagus is the development of cancer of the esophagus. For this reason, your physician will recommend yearly upper endoscopies to rule out cancer. Upper endoscopy is essentially the only way to definitively make the diagnosis of Barrett's esophagus and to exclude the diagnosis of cancer of the esophagus. Other possible complicating features include bleeding from ulcers in the esophagus and narrowing, or stricture, of the esophagus.

The goal of treatment is to prevent acid from refluxing back up the esophagus. This protects the lining of the esophagus and hopefully prevents the development of Barrett's esophagus. This is theoretical, and at the time of this writing there is no definite evidence that any treatment prevents the development of Barrett's esophagus. Nevertheless, it is prudent to decrease the amount of acid injuring the lining of the esophagus. This can be accomplished with a variety of classes of drugs including antacids, H₂-antagonists (ranitidine, famotidine, cimetidine), proton pump inhibitors (omeprazole, lansoprazole), or prokinetic agents called metoclopramide or cisapride.

As mentioned above, cancer screening of the esophagus is recommended in all patients diagnosed with Barrett's esophagus.

• Remember that the only way to make the diagnosis is by tissue biopsy via upper endoscopy. This is best done by a gastroenterologist (a medical subspecialist with expertise in diseases of the stomach and bowel).
• Remember that acid reflux tends to occur during the night when you are lying flat in bed. For this reason, your physician will recommend keeping the head of the bed elevated by placing 4 to 6 inch blocks under the bedpost.
• Lose weight, since the excess abdominal fat increases abdominal pressure, thereby increasing the amount of acid refluxing into the esophagus.

• Don't drink. Alcohol increases acid reflux.
• Don't eat large meals before going to bed.
• Don't forget that certain drinks and foods such as coffee, chocolate, and fatty foods can increase acid reflux. In addition, certain classes of medications such as calcium channel blockers can also trigger the acid reflux.

• If you have heartburn unrelieved with antacids.
• If your food gets stuck and you have to regurgitate it.
• If you have difficulty swallowing, causing weight loss.
• If you need a referral to a gastroenterologist.
• If you vomit any blood.

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