 Heartburn is a burning sensation felt behind the breastbone
and sometimes in the neck and throat. It is caused by stomach
acid refluxing or splashing up into the esophagus-the muscular
tube that connects the throat to the stomach. At the lower end of
the esophagus where it enters the stomach, there is a strong
muscular ring called the Lower Esophageal Sphincter (LES). The
LES should remain tightly closed, except to allow food and liquid
to pass into the stomach. Heartburn occurs when the LES opens at
the wrong time. Almost everyone has this occasionally, and it is
nothing to be concerned about. However, heartburn that is severe
or that occurs over a long period of time can be harmful. This is
known as Gastroesophageal Reflux Disease (GERD). If GERD is
untreated, there is constant acid irritation to the lining of the
esophagus, and complications can occur. About 1 in 10 patients
with GERD are also found to have a condition called Barrett's
esophagus. It can be serious and may lead to cancer of the
esophagus.
What is Barrett's Esophagus?
The cells lining the esophagus differ from those lining the
stomach or intestines, mainly because they have different
functions. They also have a distinctly different appearance, so
it is easy for a physician to tell them apart when examining the
esophagus and stomach. Normally, there is an area at the end of
the esophagus that marks the border between the cells of the
esophagus and those of the stomach. Barrett's esophagus is
the abnormal growth of stomach or intestinal-type cells above
this border, into the esophagus. The Barrett's tissue may
spread evenly up into the esophagus, or it may be present as
islands or finger-like projections. Usually it is found in the
lower portion of the esophagus. However, it may extend throughout
the esophagus, or even be found by itself in the middle or upper
esophagus. Since the cells lining the stomach are accustomed to
contact with acids, their growth into the esophagus may actually
be a defense mechanism. It is designed to protect the normal
tissue in the esophagus against further damage by GERD. This may
explain why the symptoms of GERD seem to lessen in some patients
with Barrett's esophagus. Unfortunately, these tissue changes
may be a forerunner of cancer of the lower esophagus, known as
adenocarcinoma. Cancer of the upper esophagus (squamous; cell
cancer) is usually related to alcohol and smoking. This type of
cancer appears to be decreasing in the population, while the rate
of adenocarcinoma is increasing sharply, especially in white
males. After many years, the Barrett's cells in some patients
may develop abnormal changes known as dysplasia. These changes
may be in the size or appearance of cells, or in the way the
cells grow. Over a period of perhaps two to five years, the
dysplasia may progress from low grade, to moderate, to high
grade, and finally to cancer. Fortunately, this happens only in
about 5% of patients with Barrett's esophagus.
Cause and Symptoms
 For unknown
reasons, Barrett's esophagus is found three times more often
in males than in females. In some instances, Barrett's
esophagus appears to be congenital (present at birth). However,
current evidence is strong that in most instances, it develops as
a result of chronic or longstanding GERD.
In most cases, patients with Barrett's would have symptoms
similar to those produced by chronic GERD. Some Barrett's
patients may also suffer from other complications of GERD, such
as peptic ulcers and stricture-narrowing of the esophagus that
comes from scarring. GERD patients with excess acid production or
frequent reflux of bile are more likely to develop Barrett's
esophagus. This is why it is important for patients with frequent
or severe heartburn to see their physicians regularly.
Diagnosis
Diagnosis of Barrett's esophagus requires an endoscopic
examination. This is done with the patient under sedation. The
physician examines the lining of the esophagus and stomach with a
thin, lighted, flexible tube called an endoscope. Biopsies are
performed, taking pieces of the abnormal tissue to examine under
a microscope for dysplasia. If there is dysplasia, then follow-up
exams must be performed.
Treatment
Currently, there is no recognized treatment to reverse
Barrett's esophagus. However, it appears that treating the
underlying GERD may slow the progress of the disease and prevent
complications. Following are some things the patient can do to
help reduce acid reflux and strengthen the LES.
- Avoid eating anything within three hours before bedtime.
- Avoid smoking and tobacco products. Nicotine in the blood
weakens the LES.
- Avoid fatty foods, milk, chocolate, mints, caffeine,
carbonated drinks, citrus fruits and juices, tomato products,
pepper seasoning, and alcohol (especially red wine).
- Eat smaller meals; avoid tight clothing or bending over after
eating.
- Review all medications with the physician. Certain drugs can
weaken the LES.
- Elevate the head of the bed or mattress 6 to 8 inches. This
helps to keep acid in the stomach by gravity. Pillows by
themselves are not very helpful.
- Lose weight if overweight. This may relieve upward pressure
on the stomach and LES.
The physician may prescribe medications for acid reduction,
such as Zantac, Pepcid, Axid, and Tagamet (generic: cimetidine).
Newer medications, such as Prilosec and Prevacid, can almost
eliminate stomach acid entirely. These drugs are almost always
needed to treat severe GERD. Reglan (generic: metoclopramide) and
Propulsid are drugs that can strengthen the LES.
Certain patients with GERD may need surgery to strengthen the
LES. This type of surgery is called fundoplication. It is often
done by laparoscopy. Laparoscopy is minimally invasive surgery,
performed with a tiny incision at the naval and a few needle
points in the upper abdomen. The patient usually returns home in
l-2 days.
A diagnosis of Barrett's esophagus requires regular
monitoring by a physician. While it is thought that controlling
GERD reduces the risk of developing cancer, this has not yet been
definitely proven. Therefore, the physician must perform regular
endoscopy exams and biopsies to look for dysplasia. Just how
often these exams are repeated depends on how far the disease has
advanced. If cancer is found, surgery to remove the lower
esophagus (esophagectorny) is usually necessary. Physicians often
recommend this procedure when a high grade of dysplasia is
present, so as to prevent the cancer that is likely to occur.
There are also new experimental treatments being studied. They
include laser destruction of the abnormal Barrett's tissue,
and a process called photodynamic therapy. In this treatment, a
special drug is injected into the bloodstream and is absorbed
only by the dysplastic cells. These cells are then destroyed when
exposed to a special frequency of red light. It is too soon to
know how effective these treatments will be, but the early data
is promising.
Summary
Barrett's esophagus is a condition that may develop as a
result of chronic GERD. Barrett's tissue growing in the
esophagus is the body's defense against continued stomach
acid irritation. Yet, this tissue does not belong in the
esophagus, and for some patients, it increases the risk of
developing adenocarcinoma (cancer) of the esophagus. While there
is no treatment to reverse this condition, the likelihood of
developing cancer and complications can be reduced with a
combination of diet, lifestyle changes, medication, and/or
surgery. A regular program of endoscopic examination and biopsy
is essential to monitor the Barrett's tissue. There are also
promising new techniques under investigation. By working closely
with a physician, patients with Barrett's esophagus can
expect good control of both GERD and Barrett's, and an
excellent long-term outcome.
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