Barrett's Esophagus is a condition of the distal esophagus in which the normal
mucosa is replaced by a different kind of lining. This is thought to be an
adaptive response to protect from acid and bile. This is a pre-cancerous condition
and requires regular endoscopic surveillance by a gastroenterologist.
When the distal esophageal mucosa (inner lining) has been exposed to a large
amount of acid and bile salts for a long time, the lining changes it's nature
(metaplasia) to accommodate this hostile environment. These changes include
the development of gastric (stomach) and intestinal type mucosa in the distal
esophagus (specialized columnar epithelium). The distal esophageal mucosa that
has undergone two stages of character change (gastric to intestinal metaplasia)
has the potential to become malignant.
The risk factors for Barrett's esophagitis are: hiatus hernia, incompetent
lower esophageal sphincter, hyperacidity and acid reflux, and an incompetent
pyloric sphincter. The latter promotes bile reflux from the duodenum into
the stomach and finally up to the esophagus.
The risk factors for developing
malignancy in BARRETT's esophagus are: 1) large hiatal hernia > 3cm, 2) length of Barrett's mucosa > 7cm,
and 3) presence of dysplasia at the time of surveillance.
Treatment of Barrett's esophagitis is treatment of reflux related symptoms
and signs. However Barrett's patients are in need of periodic surveillance
to watch for developing malignancy. Neither the lack of reflux symptoms,
nor the treatment of reflux through medical or surgical methods eliminate
the need for this surveillance. We have seen three patients with Barrett's
esophagitis associated with severe peptic esophagitis, which developed carcinoma
during a short follow-up interval. The only other common denominator in all
three was rapid healing of the peptic inflammatory process by a proton pump
inhibitor. We have never seen progression or regression of the Barrett's
lining with medical or surgical treatment of reflux. However, others have
reported regression in patients with short segment Barrett's and no hiatal
hernia. Laser ablation of the abnormal mucosa and endoscopic mucosectomy
are amongst the new and promising therapeutic endeavors.