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Ah, another big, wonderful Sunday brunch! A few cups of coffee with your bacon and eggs, and you'll lie down with the Sunday paper for a relaxing afternoon on the sofa. Nothing could ruin that perfect scenario, right? Nothing but a painful burning sensation in your chest known as heartburn. Did you know that heartburn can be more than just a nuisance? Sometimes, it can be deadly. If you or a loved one have this problem on a regular basis, you should read Dr. Richard Kim's update on Barrett's Esophagus.

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 issue 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 or LES, 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 as seen in the esophagus photos below:

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 as can be seen below:

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 Barrett's Esophagus.

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 over 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. Click on the videoclip below to see what the doctor sees in a case of typical Barrett's Esophagus:

Why Bother Checking For Barrett's?
Anytime a cell type 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 diagnosed.

What Treatments Are 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, Zegerid, omeprazole, 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 swallowing.

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 three years.

What If Dysplasia Is Found?
Biopsies taken during the scope test are sent for microscopic analysis to 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 - like an abnormal Pap Smear. 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 gastroscopy 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 (termed a Nissen Fundoplication) 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 stomach lining.

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. Recent interest has revolved around the HALO system. This system uses radiofrequency energy delivered by a balloon that has a series of closely spaced electrodes. In this way, the entire circumference of the esophagus can be treated with thermal energy in a controlled fashion. 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.

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.

New research is ongoing utilizing liquid nitrogen applied through the gastroscope as a means of freezing and ablating Barrett's esophagus with dysplasia. Early results are promising but more research is needed.

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.

Summary
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. 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 dysplasia. 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.