Barrett's oesophagus is found in about 2% of the adult population and in 5% of persons with gastro-oesophageal reflux disease (GORD) writes Fergus Bescoby.
Very few people with this condition go on to develop cancer (1-5%). It must be mentioned however that most cases remain undiagnosed and the prevalence may be much higher than appreciated.
The condition was first described in 1950 by Dr. Norman Barrett, a British thoracic surgeon. Since this original description, numerous advances have been made in the understanding of Barrett's esophagus.
The oesophagus (gullet) is the muscular tube that carries food from the mouth to the stomach. Normally, it is lined by layers of short, squat cells, called squamous cells. This multi-layered lining is similar to the skin, protecting the oesophagus from injury when swallowing food. It has a very pale pink colour.
‘Reflux' occurs when juices from the stomach and small bowel flow back up into the gullet repeatedly, over an extended period. This exposure to acid and bile can injure its lining. This is called oesophagitis.
In some cases, when the gullet heals, the normal squamous lining is replaced by cells that resemble the stomach or intestine; a process called metaplasia or change in cell shape.
It is this abnormal lining, which has a much deeper salmon red colour, which is called Barrett's Oesophagus. It can affect men and women although it is more common in men.
The cell changes in Barrett's oesophagus can sometimes develop into dysplasia (also called precancerous). Dysplasia can be either low-grade or high-grade. In low-grade dysplasia, the cells are slightly abnormal. In high-grade, the cells are more abnormal.
Barrett's oesophagus is not itself a cancerous condition. However, over a period of time it can occasionally lead to cancer of the oesophagus.
Cancer develops when cells in the affected area continue to grow and reproduce, and become increasingly abnormal.
Causes of Barrett's oesophagus
• Acid reflux
This happens when the valve at the lower end of the oesophagus is weak and allows stomach contents to splash up into the oesophagus. Reflux of acid is very common and many people have symptoms at some point in their lives.
Certain factors can make people more likely to have reflux. These include:
being overweight
smoking
excessive alcohol consumption
eating spicy, acidic, or fatty foods.
Acid reflux can also be caused by a hiatus hernia. A hiatus hernia is when a small piece of the stomach is displaced and pokes through the diaphragm. The diaphragm is the sheet of muscle that divides the stomach area from the chest.
• GORD (gastro-oesophageal reflux disease)
This is when stomach acid irritates the oesophagus. The stomach produces acid to help digest food. While the stomach is lined by tissue that's resistant to acid, the oesophagus isn't. In some people, the acid can inflame and irritate the oesophagus, causing pain and heartburn.
This is often referred to as gastro-oesophageal reflux disease (GORD) or reflux oesophagitis.
Up to 1 in 10 people with acid reflux will develop Barrett's oesophagus. It is more likely to happen in people who've had severe reflux for many years and even more likely in people over age 50.
Signs and symptoms of Barrett's oesphagus
Some people have no symptoms at all and Barrett's oesophagus is discovered during tests for other medical conditions.
The most common symptom however is ongoing heartburn and indigestion. Other symptoms include nausea, vomiting and difficulty swallowing food. Less commonly, there may be blood in the vomit or pain when swallowing food.
How Barrett's oesophagus is diagnosed
• Endoscopy
This is a procedure to examine the lining of the oesophagus. Endoscopies can also be used to give treatment. It involves examining the oesophagus using a thin, flexible tube called an endoscope.
• Surveillance
Often, people with Barrett's oesophagus are advised to have their condition monitored. This means checking at regular intervals for any further changes in the cells. It is known as surveillance and usually involves regular endoscopies and biopsies.
The endoscopies will be done at intervals ranging from every three months to every three years. This will depend on whether the condition is changing and what the degree of change is.
Treatment for Barrett's oesophagus
Treatment for Barrett's oesophagus aims to reduce acid reflux and control symptoms. Research is ongoing into new ways to diagnose and treat the condition.
• Lifestyle changes
Sometimes, it's possible to reduce acid reflux by making some lifestyle changes. Losing weight (if necessary), stopping smoking and drinking less alcohol may help. Eating small meals at regular intervals, and avoiding foods that aggravate symptoms can also help.
• Medicines to reduce acid
Certain medicines can be taken to decrease the production of stomach acid. These include proton pump inhibitors (PPI) or histamine receptor blockers. This will help reduce the symptoms of Barrett's oesophagus.
• Fundoplication
This is an operation to strengthen the valve at the bottom of the oesophagus. During the operation, the top of the stomach (the fundus) is wrapped and stitched around the lower end of the oesophagus. This strengthens the lower end of the oesophagus, and should help reduce acid reflux. Fundoplication is often done using keyhole surgery.
• Repairing a hernia
An operation to repair a hiatus hernia may also help to reduce acid reflux. Very occasionally, a hiatus hernia can affect the chest area (known as a complicated hiatus hernia). In this situation, a chest operation may be necessary.
• Removing the affected area
If a biopsy shows that there are continuing changes in the cells, which may progress to cancer (dysplasia), the affected area may be removed. There are two main procedures - endoscopic mucosal resection and surgical resection.
Endoscopic mucosal resection
The aim of this surgery is to remove only the affected area of the oesophagus lining, without damaging the rest of the oesophagus. This is done using an endoscopy.
Surgical resection
Sometimes, more extensive surgery is needed. The surgeon will remove the section of the oesophagus that contains the abnormal cells. The stomach is then joined to the remaining part of the oesophagus.
• Endoscopic treatments
These involve using an endoscope to deliver treatments that destroy abnormal cells in the oesophagus lining. An endoscope is a thin, flexible tube.
• Radiofrequency ablation (RFA)
RFA uses heat to destroy abnormal cells. A probe called an electrode is used to give an electrical current (radiofrequency) to the abnormal area. The electrical current heats the abnormal cells to a high temperature, which then destroys (ablates) them.
• Other endoscopic techniques
Other ways of treating Barrett's oesophagus include argon plasma coagulation, photodynamic therapy (PDT), multipolar electrocoagulation and cryotherapy.
Underwriting implications
A targeted GPR will generally be requested and this should include the results of any endoscopic examinations and biopsies which will confirm the actual level of cellular changes.
Details of any regular surveillance plan, treatment and any possible complications will all assist the underwriter in reaching a final decision.
Terms will depend on the level of metaplasia or dysplasia present (if applicable), the form of treatment being used and the level of surveillance being undertaken.
Fergus Bescoby is underwriting development manager at VitalityLife.
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