Reflux: Overview of Barrett's Esophagus
Transcript:
Guest:
Host: Dr. Linda Austin – Psychiatry
Dr. Linda Austin: I am Dr. Linda Austin and I am talking, today, with Dr. Marcelo Vela who is a gastroenterologist at the Medical University of South Carolina and a real expert on diseases of the esophagus. Dr. Vela, there is a particular disease called Barrett’s esophagus. Just what is that?
Dr. Marcelo Vela: Barrett’s esophagus is a change in the lining in the esophagus that occurs as a result of long term reflux. So, patients who have had reflux for many years may develop this change in the lining of their esophagus.
Dr. Linda Austin: Now, the esophagus is the tube that food passes through, that goes from your mouth down to your stomach. So, when there has been reflux, or acid contents going up over a long period of time, that can lead to Barrett’s. Do I have that right?
Dr. Marcelo Vela: Yes, that is correct. The esophagus is the swallowing tube that transports food from the mouth into the stomach. It is normally lined by a certain type of cell, called a squamous cell. Some patients who have had acid reflux for many years, these squamous cells are replaced by a different type of cell, called an intestinal cell. The intestinal cells are more resistant to acid and so it makes sense for the esophagus to change its lining to the intestinal-type. However, having the Barrett’s increases the risk of developing a cancer in the esophagus.
Dr. Linda Austin: Now, how would a patient begin to suspect that they might have transitioned from chronic reflux to Barrett’s esophagus?
Dr. Marcelo Vela: Well, unfortunately, the patient will not be able to know whether this change has occurred based exclusively on symptoms. The patient will just have heartburn for many years and nothing will really change. If anything, their heartburn may become a little less severe, or less frequent, because they have a more resistant, if you will, lining in the esophagus. So, there is no way to tell based upon symptoms.
Dr. Linda Austin: Now, as a gastroenterologist, one who specializes in this, what would lead you to suspect of Barrett’s, and what would lead you to even think to do the diagnostic tests in a given patient?
Dr. Marcelo Vela: We recommend looking for Barrett’s in anybody who has had reflux symptoms for a good number of years. So, we recommend testing for Barrett’s in anybody who has had prolonged symptoms of reflux. Now, what prolonged means is a matter of controversy, but anywhere between 5 and 10 years of symptoms should prompt an evaluation for Barrett’s.
The condition is a little more common in males as opposed to females and in whites as opposed to other races. So, if you have a white male with prolonged reflux, you really need to test for Barrett’s.
Dr. Linda Austin: Are there any other risk factors that would make you concerned such as smoking or alcohol or anything else?
Dr. Marcelo Vela: It is not very well established. Obesity may be a risk factor, but the real critical predictor is having reflux symptoms for many years.
Dr. Linda Austin: How do you, then, make that diagnosis?
Dr. Marcelo Vela: The diagnosis of Barrett’s esophagus is based upon endoscopy which is an examination of the lining of the esophagus. The appearance of the esophagus changes when there is Barrett’s and it is something we can see on endoscopy. This has to be confirmed by biopsy, meaning, we take a small sample from the esophagus. If it looks suspicious for Barrett’s, we send it to the pathology laboratory and then the pathologist, under the microscope, can confirm whether Barrett’s is present.
Dr. Linda Austin: So, describe, now, that process of the endoscopy. It sounds like one of those procedures that really are not too crazy about having. What happens?
Dr. Marcelo Vela: Well, it is a very short procedure. It takes about 10 minutes to perform it. We do under sedation, so the patients are fairly sleepy for it and most of them do not actually remember having the procedure. So, it does not pose a great deal of discomfort because the patients are sedated.
The endoscope is a long thin tube with a light and a camera at the end. We go in through the mouth, past the throat and into the esophagus. Under direct vision, we inspect the esophagus. We normally also inspect the stomach and the first portion of the small bowel. Through the instrument, we can pass a small forceps, a little instrument with jaws that can take out a tiny portion of the lining which is then retrieved and sent to the laboratory for confirmation of Barrett’s.
Dr. Linda Austin: If, indeed, there is Barrett’s esophagus, what is the treatment?
Dr. Marcelo Vela: Well, patients need to be on reflux medication because ongoing exposure to acid can result in progression of Barrett’s to cancer, so that is one thing. Nowadays, we a recommending that patients take a small dose of aspirin on a daily basis because there is data suggesting that this may decrease the risk of progression to cancer.
Dr. Linda Austin: How often, then, does the patient have to be re-checked after that initial check?
Dr. Marcelo Vela: This really depends on the changes that are present under the microscope. Barrett’s comes in different flavors, if you will. There is just Barrett’s esophagus alone with no dysplasia. Now, dysplasia one of the early changes before the epithelium, or the lining, transforms into cancer. So, there is Barrett’s with low-grade dysplasia, Barrett’s with high-grade dysplasia, and then cancer.
The period of time that has to elapse before you get re-checked with another endoscopy depends on whether there is dysplasia in your biopsies. Most patients do not have dysplasia and they need a repeat endoscopy in three years. It may be that we will soon move to a five-year interval as we are finding out it is most likely safe to do that.
The important thing is to be on a surveillance program because patients that are on a surveillance program, if a cancer develops, which is rare, they will invariably be caught at an early stage where the disease is curable.
Dr. Linda Austin: How common is this diagnosis?
Dr. Marcelo Vela: That is a very important question actually, how frequently do patients with Barrett’s go on to develop a cancer? The answer is, a very small number of patients develop cancer. If you compare patients who do not have Barrett’s with patients that do have Barrett’s, those with Barrett’s have an increased risk of developing cancer but it is a very small increase in this risk. So, most patients with Barrett’s will actually never go on to develop a cancer. It is a very small rate. But, it is important that they do stay on their surveillance program because, as I said before, if they do have a cancer, the surveillance program will enable diagnosis at an early and curable stage.
Dr. Linda Austin: Dr. Vela, thank you so much for talking with us today.
Dr. Marcelo Vela: My pleasure.
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