Pathophysiology
Barrett’s oesophagus is metaplasia (abnormal, reversible change of tissue from one cell type to another) of the normal oesophageal epithelial lining. Normally the oesophagus is stratified squamous epithelium but in Barrett’s, it changes to simple columnar epithelium. It occurs as a result of chronic exposure to gastric acid, as seen in GORD.
Barrett’s oesophagus can be divided into short and long Barrett’s oesophagus (<3cm vs >3cm).
It is a “premalignant” condition that poses a risk for adenocarcinoma. The risk increases approximately 50-100x with Barrett’s. The metaplastic transformation is not an issue, except for the increased risk for dysplasia or neoplasia.
⚠️ Risk factors
- Ethnicity - Caucasian
- Gender - Male (7:1)
- Age - >50 years old
- Lifestyle - smoking, obesity
- Comorbidities - hiatus hernia, GORD.
🔍 Investigations
Often patients with dyspepsia or upper GI symptoms will have an endoscopy, and this is how Barrett’s may be identified. Approximately 12% of patients undergoing endoscopy for reflux are found to have Barrett’s. There are no independent screening programmes.
🏆 Endoscopically visible metaplasia needs to be biopsied to confirm diagnosis of Barrett’s oesophagus.
🧰 Management
- PPI (e.g. omeprazole, lansoprazole) should be started at a high-dose and bidaily. This reduces the risk of progression to dysplasia
⚠️ NSAIDs and other medications that disrupt the stomach barrier should be stopped.
Patients should undergo regular endoscopic surveillance. The frequency depends on the histology present:
Histology | Endoscopy | |
Metaplasia with no dysplasia | Every 2 to 5 years | |
Low grade dysplasia | Every 6 months | Repeat endoscopy with quadrantic biopsies every 1cm |
High grade dysplasia | Every 3 months | If a visible lesion is present, endoscopic ablation with mucosal resection (EMR) or radiofrequency ablation should be considered |
🥇 Endoscopic mucosal resection (EMR) ➡️
Endoscopic submucosal dissection (ESD)
Radio-frequency ablation (RFA) ⬇️
