1. What is Barrett esophagus?

        During an upper endoscopy, if your doctor finds segments of red and velvety tissues in the lower esophagus instead of the usual pale and glossy esophageal linings,  you have probably got Barrett esophagus. When the pathologist finds that metaplastic columnar epithelium( the red one) has replaced the normal stratified squamous mucosa( the pale one), you have a definite diagnosis of Barrett. 

2. What are the symptoms of Barrett esophagus? When should I see a doctor?

     BE patients have symptoms similar to gastroesophageal reflux disease(GERD), including: heartburn, regurgitation of gastric contents, swallowing difficulty, or less commonly, chest pain. Approximately half of the people diagnosed with BE report little if any symptoms of acid reflux.

If you've had trouble with heartburn, regurgitation and acid reflux for more than five years, then you should ask your doctor about your risk of BE.  Seek immediate help if you have chest pain, have swallowing difficulty or have signs of gastrointestinal bleeding like vomiting blood or passage of black, tarry stools.

3. I have long time heartburn, how should I improve my lifestyle ?

        Heartburn is a typical feature of GERD, among which less than 20 percent of people will have abnormal endoscopic findings. If you have five years or more of reflux symptoms, GERD symptoms from a young age,obesity and a history of smoking, you have an increased risk of being diagnosed with BE.

Maintaining a healthy weight, quitting smoking, and avoiding foods/drinks that may exacerbate GERD symptoms (e.g., chocolate, peppermint, fatty foods, coffee, tea, sodas, alcohol) will help you control your GERD symptoms and hopefully lower the incidence of BE.

4. What is the significance of the surveillance of Barrett esophagus? 

        Esophageal adenocarcinoma(EAC) has now replaced squamous cell carcinoma as the most common type of esophageal malignancy in the Western world. It is aggressive and usually presents late with a poor prognosis with an overall 5-year survival below 10% to 20% .  BE is the only known precursor to this kind of cancer with a population prevalence of around 1–2%.  The progression of BE to EAC is stepwise, through  intestinal metaplasia to low-grade dysplasia(LGD) to high-grade dysplasia (HGD) to intramucosal EAC and finally to invasive EAC. So early detection and treatment of BE will help keep this deadly killer at bay. (LGD means that the cells show small signs of precancerous changes while HGD, many changes. HGD is thought to be the final step before cells change into esophageal cancer.)

5. Who should be screened for Barrett esophagus?

        The American College of Gastroenterology recommended screening for  men who have had GERD symptoms at least weekly that don't respond to treatment with proton pump inhibitor (PPI) medication, and who have at least two more risk factors, including: having a family history of Barrett's esophagus or esophageal cancer, being over 50, being a current or past smoker,being obese.

While women are significantly less likely to have Barrett's esophagus, women should be screened if they have uncontrolled reflux or have other risk factors for Barrett's esophagus.

6. I have BE, how often should I be screened for changes to my esophagus?

          The aim of surveillance of BE is to identify dysplasia and malignancy, but cost -effectiveness might be taken into account. Strategies of surveillance are mainly based upon accurate diagnosis of histology.

         For metaplasia and non-dysplastic disease , if the maximal length of the segment of Barrett is less than 3 cm,surveillance every 3-5 years is recommended; if above 3cm, 2-3 years is recommended.

          If indefinite for dysplasia, American and British guidelines emphasize maximal acid suppression with a PPI to reduce the misleading effects of reflux esophagitis on the esophageal mucosa.  After 3-6 months  adequate acid suppression,  further biopsies should be taken to clarify the diagnosis by expert esophageal histopathologist.

          If a histological finding of LGD is encountered, a repeat endoscopy should be performed at 6 months. If this confirms the diagnosis, discussions should be had regarding endoscopic surveillance (every 6 months for 2 years, annually thereafter) or eradication therapy.

         When HGD is encountered, two expert GI pathologists should analyse the samples and patients should be referred to a tertiary centre for consideration of repeat endoscopy, biopsies, endoscopic  resection and eradication therapy.

7. Are there new endoscopic techniques to accurately diagnose  BE  with minimal biopsies?

        Great progress has been made in the development of endoscopy and many are available at most GI centers, including:High‑resolution endoscopy, chromoendoscopy, confocal laser endomicroscopy, NBI, Magnifying endoscopy.

8. What is endoscopic eradication therapy for BE and BE related neoplasia?

        Endoscopic resection uses an endoscope to remove damaged cells to aid in the detection of dysplasia and cancer, while radiofrequency ablation uses heat to remove abnormal esophagus tissue. Endoscopic eradication therapy includes endoscopic mucosal resection (EMR), endoscopic submucosal dissection(ESD)  and ablative techniques.

        In BE patients with LGD, endoscopic eradication therapy is recommended on condition that the patient be fully prepared for adverse events. BE patients with HGD, RFA was more effective and less costly than endoscopic surveillance. BE patients with HGD or intra-mucosal EAC, endoscopic eradication therapy is  recommended rather than surgery.

9.What is esophageal cancer? 

          Esophageal cancer is the growth of malignant cells usually arising from the lining of the esophagus. Esophageal cancer can be divided into two groups: squamous cell carcinoma and adenocarcinoma. Squamous cell carcinoma may occur throughout the length of the esophagus whereas adenocarcinoma normally occurs just above the esophagogastric junction. Esophageal cancer may be totally asymptomatic in the early stages or may present with nonspecific complaints that may include heartburn, atypical chest pain or dyspepsia. Other presenting symptoms may include difficulty swallowing, weight loss or pain on swallowing.

10. Is esophageal adenocarcinoma common in China? Which treatment is the most effective?

          EAC is most common in industrialized countries with populations of predominant European race; nearly 50% of all cases occur in Northwest Europe and North America. Incidences are highest in the United Kingdom, Ireland, France, and the Netherlands, indicating a Northern European predilection. It is rare in Asia and Africa, but China has approximately 18% of all incident cases worldwide, due to its large population.

        The guidelines recommend that an endoscopic resection is indicated for patients with early stage neoplasia( T1a or superficial pT1b tumors that are ≤3 cm in tumor diameter), having no clear lymphovascular invasion , and having no poorly differentiated histology.

         Surgery is the most effective strategy to cure localized early stage disease. However, surgery alone is usually inadequate in advanced cases. Preoperative chemoradiation or  perioperative chemotherapy are currently utilized as an adjunct to surgery. Radiation therapy, either palliative or curative, is another well-accepted treatment. Chemotherapy in conjunction with radiation therapy has been shown to be superior to radiation therapy alone in patients who are not surgical candidates.

References:

1. Amadi C, Gatenby P. Barrett’s oesophagus: Current controversies.World J Gastroenterol, 2017, 23(28): 5051-5067.

2. Maitra I,Date RS, Martin FL. Towards screening Barrett’s oesophagus: current guidelines, imaging modalities and future developments.Clinical Journal of Gastroenterology,2020,13:635-649.

3. Steele D, Baig KKK, Peter S. Evolving screening and surveillance techniques for Barrett's esophagus. World J Gastroenterol, 2019,25(17): 2045-2057.

4. Endoscopic eradication therapy for patients with Barrett’s esophagus–associated dysplasia and intramucosal cancer.https://doi.org/10.1016/j.gie.2017.10.011.

5. Zhang XT, Anandasabapathy S, Abrams J, et al. Lifestyle Risk Factors, Quality of Life,and Intervention Preferences of Barrett’s Esophagus Patients: A Prospective Cohort Study. Global Advances in Health and Medicine,2021, Volume 10: 1-12.

6.https://www.hopkinsmedicine.org/health/conditions-and-diseases/heartburns-hidden-cancer-risk.

7.https://www.mayoclinic.org/diseases-conditions/gerd/symptoms-causes/syc-20361940

8.Harada K, Rogers JE, Iwatsuki M, et al. Recent advances in treating oesophageal cancer. F1000Research, 2020. https://doi.org/10.12688/f1000research.22926.1.