Overview
Barrett's Oesophagus
1. Overview
Barrett's Oesophagus is a pre-malignant condition characterized by the replacement of the normal stratified squamous epithelium of the distal oesophagus with metaplastic columnar epithelium (containing goblet cells).
It is a direct complication of chronic Gastro-Oesophageal Reflux Disease (GORD) and acts as the precursor lesion for Oesophageal Adenocarcinoma.
Epidemiology
- Prevalence: 1-2% of general population (higher in GORD).
- Risk Profile: Obese, White Male, age >50, Chronic GORD (>5 years).
- Cancer Risk: Low but significant (approx 0.3% - 0.5% per year).
2. Pathophysiology
┌─────────────────────────────────────────────────────────────────────────────┐
│ BARRETT'S PATHOPHYSIOLOGY │
├─────────────────────────────────────────────────────────────────────────────┤
│ │
│ ┌─────────────────────────────────────────────────────────────────────┐ │
│ │ CHRONIC ACID EXPOSURE (GORD) │ │
│ │ • Acid and Bile reflux damaging the distal oesophagus. │ │
│ └─────────────────────────────────────────────────────────────────────┘ │
│ ↓ │
│ ┌─────────────────────────────────────────────────────────────────────┐ │
│ │ METAPLASIA (The switch) │ │
│ │ • The body tries to protect itself. │ │
│ │ • Squamous cells (fragile to acid) are replaced by Columnar cells │ │
│ │ (tougher, intestine-like). │ │
│ │ • "Salmon-pink" mucosa replaces "Pale-pink" mucosa. │ │
│ └─────────────────────────────────────────────────────────────────────┘ │
│ ↓ │
│ ┌─────────────────────────────────────────────────────────────────────┐ │
│ │ DYSPLASIA (The danger) │ │
│ │ • Disorderly growth within the metaplasia. │ │
│ │ • Low Grade -> High Grade. │ │
│ └─────────────────────────────────────────────────────────────────────┘ │
│ ↓ │
│ ADENOCARCINOMA │
│ │
└─────────────────────────────────────────────────────────────────────────────┘
3. Clinical Features
- Symptoms: Usually causes NO symptoms itself. The patient has symptoms of GORD (heartburn, regurgitation).
- Silent Barrett's: Many patients are asymptomatic until cancer develops.
- Warning Signs: Dysphagia (difficulty swallowing) suggests progression to stricture or malignancy.
4. Diagnosis
Gold Standard: Upper GI Endoscopy (OGD) with Biopsy.
1. Endoscopic Appearance
- Migration of the Z-line (Squamo-columnar junction) proximally.
- Salmon-pink tongues extending up from the stomach.
2. The Prague Criteria (Reporting Standard)
- C value: Circumferential extent (e.g., C2 = 2cm continuous ring).
- M value: Maximum extent of tongues (e.g., M5 = 5cm tongue).
3. Histology
- Required for diagnosis.
- Must show Intestinal Metaplasia (Columnar epithelium with Goblet cells).
5. Management Algorithm
Management depends on the presence of Dysplasia.
┌─────────────────────────────────────────────────────────────────────────────┐
│ BARRETT'S MANAGEMENT PROTOCOL │
├─────────────────────────────────────────────────────────────────────────────┤
│ │
│ DIAGNOSIS CONFIRMED (Non-Dysplastic) │
│ • PPI Treatment: Full dose mainly for symptom control. │
│ • Surveillance Endoscopy: │
│ - Short segment (<3cm): Every 3-5 years. │
│ - Long segment (>3cm): Every 2-3 years. │
│ └─────────────────────────────────────────────────────────────────────┘ │
│ ↓ │
│ ┌─────────────────────────────────────────────────────────────────────┐ │
│ │ LOW GRADE DYSPLASIA (LGD) │ │
│ │ • Confirmed by TWO expert pathologists. │
│ │ • Option 1: Optimise PPI and repeat OGD in 6 months. │ │
│ │ • Option 2: Radiofrequency Ablation (RFA) - increasingly preferred.│ │
│ └─────────────────────────────────────────────────────────────────────┘ │
│ ↓ │
│ ┌─────────────────────────────────────────────────────────────────────┐ │
│ │ HIGH GRADE DYSPLASIA (HGD) │ │
│ │ • HIGH risk of progression to cancer (or co-existing cancer). │ │
│ │ • Treatment is MANDATORY. │ │
│ │ • Endoscopic Resection (EMR) for visible nodules. │ │
│ │ • Radiofrequency Ablation (RFA) for flat mucosa. │ │
│ │ • Surgery (Oesophagectomy) rarely needed now for HGD alone. │ │
│ └─────────────────────────────────────────────────────────────────────┘ │
│ │
└─────────────────────────────────────────────────────────────────────────────┘
Endoscopic Therapy
- EMR (Endoscopic Mucosal Resection): Cutting out the lump. Staging and cure.
- Halo RFA: Burning the bad lining so healthy squamous lining grows back.
6. Surveillance Debate
- Who to screen? Routine screening of all GORD patients is not cost-effective.
- Guidelines: Screen those with chronic GORD (>5 yrs) + Multiple Risk Factors (Male, White, Obesity, Age >50, Family history).
7. Prognosis
- Non-dysplastic: Normal life expectancy. Low cancer risk.
- High Grade Dysplasia: Very curable with endoscopic therapy (>90%).
- Adenocarcinoma: Poor prognosis if advanced (5-year survival <20%).
8. Special Considerations
GORD Surgery (Fundoplication)
- Does it stop Barrett's progression?
- No strong evidence that anti-reflux surgery prevents cancer better than PPIs. It is done for symptom control, not cancer prevention.
Chemoprevention
- PPIs: Chemoprotective effect (reduces neoplastic progression).
- Aspirin: Some evidence suggests benefit, but risk of bleeding. Not routinely recommended yet.
9. Key Clinical Pearls
Exam-Focused Points
- Definition: Metaplasia of Squamous to Columnar.
- Histology: Goblet cells are the hallmark.
- Surveillance: Depends on length and dysplasia. Know the difference between "Discharge" (short segment, stable) vs "Ablate" (High grade dysplasia).
- HGD Management: RFA/EMR is first line. Oesophagectomy is a massive operation reserved for invasive cancer.
- Prague Criteria: C and M values.
Common Exam Scenarios
- 60yo male with 20yr history of heartburn. OGD shows C5 M7 salmon mucosa. Next step? (Biopolies to check for dysplasia).
- Biopsy shows High Grade Dysplasia. Management? (Refer to excessive center for RFA/EMR).
- Patient asks if he will get cancer? (Risk is low, surveillance catches it early).
10. Patient Explanation
What is Barrett's?
"It is a change in the lining of your gullet acting like a callus. Because of the acid rising from your stomach over years, the gullet has changed its skin to resemble the stomach lining, which is tougher."
Is it cancer?
"No. It is a 'pre-cancerous' condition, meaning there is a small potential for it to turn into cancer in the future. We monitor it regularly with a camera to catch any changes early."
11. Evidence & Guidelines
Key Guidelines
| Guideline | Organization | Year | Key Points |
|---|---|---|---|
| Barrett's Oesophagus | BSG (British Soc Gastro) | 2014 | Surveillance intervals and RFA. |
| Management of BE | ACG (USA) | 2016 | Similar guidelines. |
Evidence-Based Recommendations
| Recommendation | Evidence Level |
|---|---|
| RFA for High Grade Dysplasia | High (High cure rate) |
| PPI for all Barrett's | Moderate |
| Routine Screening | Low (Select high risk only) |
13. References
- Fitzgerald RC, et al. British Society of Gastroenterology guidelines on the diagnosis and management of Barrett's oesophagus. Gut. 2014;63(1):7-42.
- Shaheen NJ, et al. ACG Clinical Guideline: Diagnosis and Management of Barrett's Esophagus. Am J Gastroenterol. 2016.