Barrett esophagus is thought to have a prevalence of 3-15% in patients with reflux esophagitis. Mean age at diagnosis is 55 years old 5. Risk factors are similar to those for gastro-esophageal reflux disease (GERD).
Scleroderma is thought to be a risk factor, with ~37% of patients (n = 27) who underwent upper endoscopy were found to have Barrett esophagus 5.
Asymptomatic. Usually discovered in a workup for GERD.
Barrett esophagus represents progressive metaplasia of esophageal stratified squamous cell epithelium to columnar epithelium. Although the exact number varies, 90-100% of esophageal adenocarcinoma is thought to arise from this metaplasia.
Although patients with Barrett esophagus have a 30x risk of developing esophageal adenocarcinoma 2, the annual risk of developing adenocarcinoma depends on the degree of histological dysplasia, but may be ~1% (range 0.1-2%), and the absolute risk is low 3.
Because Barrett esophagus represents metaplasia, it is often occult on imaging. Early esophageal adenocarcinoma arising out of Barrett esophagus also may be difficult to see. Radiographic imaging modalities are not adequate for screening.
double-contrast esophagogram 7
- signs of reflux esophagitis
- long stricture in the mid or lower esophagus
- large deep solitary ulcer
- fine reticular mucosal pattern
- thickened irregular mucosal folds
- earliest signs of developing adenocarcinoma: localized flattening, stiffening, or irregularity in the wall of a stricture
- signs of reflux esophagitis
There is a ~70% chance of Barrett esophagus in a midthoracic esophageal stricture.
Treatment and prognosis
Since Barrett esophagus is considered a premalignant lesion, confirmation with upper endoscopy and biopsy is warranted.
If Barrett esophagus is confirmed on biopsy, then aggressive therapy for gastro-esophageal reflux is pursued, and perhaps endoscopic surveillance, depending on the patient's age and other risk factors.
One surveillance and biopsy protocol suggests 4:
- low-grade dysplasia: 6-12 months
- high-grade dysplasia: 3 months
If there is mucosal irregularity (what would be seen on an esophagogram), then endoscopic resection has been recommended 4. Prophylactic resection or ablation has been used by some, particularly in younger patients.
- 1. Spechler SJ. Clinical practice. Barrett's Esophagus. N. Engl. J. Med. 2002;346 (11): 836-42. doi:10.1056/NEJMcp012118 - Pubmed citation
- 2. Rastogi A, Puli S, El-Serag HB et-al. Incidence of esophageal adenocarcinoma in patients with Barrett's esophagus and high-grade dysplasia: a meta-analysis. Gastrointest. Endosc. 2008;67 (3): 394-8. doi:10.1016/j.gie.2007.07.019 - Pubmed citation
- 3. Van der Veen AH, Dees J, Blankensteijn JD et-al. Adenocarcinoma in Barrett's oesophagus: an overrated risk. Gut. 1989;30 (1): 14-8. Free text at pubmed - Pubmed citation
- 4. , Spechler SJ, Sharma P et-al. American Gastroenterological Association medical position statement on the management of Barrett's esophagus. Gastroenterology. 2011;140 (3): 1084-91. doi:10.1053/j.gastro.2011.01.030 - Pubmed citation
- 5. Spechler SJ. Barrett's esophagus. Semin. Gastrointest. Dis. 1996;7 (2): 51-60. Pubmed citation
- 6. Recht MP, Levine MS, Katzka DA et-al. Barrett's esophagus in scleroderma: increased prevalence and radiographic findings. Gastrointest Radiol. 1988;13 (1): 1-5. doi:10.1007/BF01889012 - Pubmed citation
- 7. Gilchrist AM, Levine MS, Carr RF et-al. Barrett's esophagus: diagnosis by double-contrast esophagography. AJR Am J Roentgenol. 1988;150 (1): 97-102. doi:10.2214/ajr.150.1.97 - Pubmed citation
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