Jay W. Marks, MD, is a board-certified internist and gastroenterologist. He graduated from Yale University School of Medicine and trained in internal medicine and gastroenterology at UCLA/Cedars-Sinai Medical Center in Los Angeles.
Low grade dysplasia is managed by continuing endoscopic biopsy surveillance. For these patients, however, the follow-up interval is shortened from every two to three years (which is done for Barrett's with no dysplasia) to every six months for an indefinite period of time. Esophagectomy is not considered for low grade dysplasia unless the patient develops high grade dysplasia or cancer during the surveillance.
What are the experimental approaches for treatment of high grade dysplasia?
Several experimental options are available. Patients entertaining these experimental treatments should seek out a research team that is doing studies with these techniques. For example, with these treatments, some patients need to be retreated, but long-term studies are needed to define how often retreatment is needed. Nevertheless, because they avoid the need for esophagectomy, these techniques may eventually prove to be ideal for patients who are medically not fit for surgery.
Ablation therapy
Ablation therapy involves the removal of the target tissue (for example, Barrett's mucosa, high grade dysplasia, or cancer) by procedures (such
as, laser or electrocoagulation) that literally destroy
the tissue. The results of ablation therapy in Barrett's with dysplasia (as well as without dysplasia, which is discussed in the next section) have produced two conclusions. One is that ablation succeeds in more than half the cases. The second is that the recurrence rates at different centers differ widely.
Photodynamic therapy
(PDT)
Photodynamic therapy is a powerful method of ablation therapy. This
technique involves the intravenous administration of a photosensitizing agent
(for example, sodium porfimer) that is taken up by the dysplastic Barrett's cells. Approximately 48 hours later, a laser is used to burn the photosensitized Barrett's cells which are sensitive to the laser because of the photosensitizing agent. Normal tissue is not burned because it has not taken up the photosensitizing agent and is not sensitive to the laser. The dysplasia is eliminated in more than 75% of patients. However, some Barrett's esophagus remains untreated and need biopsy follow-up or additional ablation. Long-term studies will be necessary to demonstrate whether this technique prevents esophageal adenocarcinoma on a long term basis (for
example, five years and longer after treatment).
One disadvantage of photosensitizing therapy is that
skin takes up some of the photosensitizing agent, and this makes the skin
sensitive to normal sunlight. The sensitivity may persist for six weeks or more
and can result in sunburn even with minimal exposure to direct sunlight. Patients, therefore, must remain out of the sunlight for this period. Other photosensitizing agents being tested have much less skin sensitivity, but studies are needed to determine if they are effective in eliminating the dysplasia. Esophageal narrowings (strictures) are a common complication of PDT but can be managed by endoscopically stretching (dilating) them.
Other methods of ablation
Other experimental methods of ablation are less powerful
than PDT and have, therefore, been applied more often to low grade dysplasia and
shorter segments of Barrett's with dysplasia (as well as to Barrett's without
dysplasia, which is discussed in the next section). These methods of ablation
include argon (flame) plasma coagulation (APC) and multipolar electrocoagulation (MPEC). They work by burning off the dysplasia and the Barrett's lining cells using devices that are introduced through the endoscope.
Endoscopic mucosal resection
(EMR)
Another experimental method to treat dysplasia,
especially high grade dysplasia, is the removal of dysplastic or cancerous areas
of the mucosa by cutting (resecting) them out. The resection is done using
snares at endoscopy, in a manner similar to the way polyps of the colon are
removed at colonoscopy. Again, 5-year follow-up data
is necessary to determine if EMR is effective.
Chemoprevention with drugs
The newer drugs used to treat arthritis, the
COX-2
inhibitors, have been studied in Barrett's-associated dysplasia. The purpose of
these studies is to see if these drugs can downgrade the severity of dysplasia
or prevent dysplasia. This approach, which is called chemoprevention, is based
upon the observation that adenomatous polyps of the colon in patients with
familial polyposis (hereditary multiple colonic polyps) decrease (regress) after
treatment with these drugs or even with the older nonsteroidal antiinflammatory
drugs (NSAIDs). The theoretical reason to try COX-2
inhibitors in Barrett's dysplasia is that the enzyme cyclooxygenase (COX), which these drugs inhibit, is
present in large amounts in Barrett's dysplasia, as it is in adenomatous
polyps of the colon.
It should be stressed that long-term therapy with these
drugs in Barrett's esophagus should remain in the experimental arena because of
the complications or side effects associated with these drugs (for example,
cardiac, kidney and gastrointestinal problems).
Most sore throats are caused by viruses or mechanical causes (such as mouth breathing) and can be treated successfully at home. However, a person should be seen by a health care professional if they have a sore throat that has a rapid onset, and is associated with a fever or tenderness of the front of the neck; a sore throat that causes the person to have difficulty swallowing (not just pain swallowing) or breathing; or if a sore throat lasts for more than a week.
GERD (gastroesophageal reflux disease) is a condition in which the acidified liquid
contents of the stomach backs up into the esophagus. The symptoms of uncomplicated GERD are heartburn,
regurgitation, and nausea. Effective treatment is available for most patients with GERD.
Bronchitis is a disease of the respiratory system in which the bronchial passages become inflamed. There are two types of bronchitis, acute and chronic. Symptoms of acute bronchitis include frequent cough with mucus, lack of energy, wheezing, and possible fever. Treatment may require medication such as bronchial inhalers and predinsone. Supportive treatment is focused on relieving the symptoms with fever reducers, cough suppressants, and rest. Treatment may be more aggressive in patients with pre-existing conditions such as empyema, COPD, or cigarette smoking.
A hiatal hernia is an anatomical abnormality in which part of the stomach protrudes through the diaphragm and up into the chest. Causes of hiatal hernia are a larger than normal esophageal hiatus. There are two types of hiatal hernias, sliding, or para-esophageal. When symptoms of hiatal hernia appear, they are similar to GERD symptoms. Hiatal hernia treatment is generally surgery.
Chronic cough is a cough that does not go away and is generally a symptom of another disorder such as asthma, allergic rhinitis, sinus infection, cigarette smoking, GERD, postnasal drip, bronchitis, pneumonia, medications, and less frequently tumors or other lung disease. Treatment of chronic cough is dependant upon the cause.
Esophageal cancer is a disease in which malignant cells form in the esophagus. Risk factors of cancer of the esophagus include smoking, heavy alcohol use, Barrett's esophagus, being male and being over age 60. Severe weight loss, vomiting, hoarseness, coughing up blood, painful swallowing, and pain in the throat or back are symptoms. Treatment depends upon the size, location and staging of the cancer and the health of the patient.
Stool color is generally brown. When stool color changes, often, an individual becomes concerned. The presence of the bilirubin in bile is generally responsible for stool color. Bilirubin concentration can vary bile color from light yellow to almost black in color. Changes in bilirubin can cause stool to turn green, gray, or clay-like in color. Intestinal bleeding may turn stool black, tarry, red, maroon, or smelly stool. Medication and food may also affect stool color.
Helicobacter pylori (H. pylori) is a bacterium that causes chronic inflammation (gastritis) of the inner lining of the stomach in humans. This bacteria also is the most common cause of ulcers worldwide.
Eosinophilic esophagitis is an inflammation of the esophagus. Eosinophilic esophagitis has many causes including acid reflux, heartburn, viruses, medications that become stuck in the esophagus, allergy, asthma, hay fever, allergic rhinitis, and atopic dermatitis. Eosinophilic esophagitis symptoms include difficulty swallowing food, abdominal pain, chest pain, and heartburn.
Dysphagia or difficulty in swallowing, swallowing problems. Dysphagia is due to problems in nerve or muscle control. It is common, for example, after a stroke. Dysphagia compromises nutrition and hydration and may lead to aspiration pneumonia and dehydration.
Esophagitis is caused by an infection or irritation of the esophagus. Infections that cause esophagitis include candida yeast infection of the esophagus as well as herpes.
Gastritis is an inflammation of the stomach lining. Causes of gastritis include drinking too much alcohol, medications such as NSAIDs, ibuprofen, aspirin, H. pylori infection, severe infections, burns, anemia, and autoimmune disorders. Gastritis is diagnosed with endoscopy, blood tests, or stool tests. Treatment depends upon the cause of gastritis.
Smoking is an addiction. More than 430,000 deaths occur each year in the U.S. from smoking related illnesses. Secondhand smoke or "passive smoke" also harm family members, coworkers, and others around smokers. There are a number of techniques available to assist people who want to quit smoking.
Hoarseness (abnormal deep, harsh, raspy voice) is caused by a variety of conditions in which the larynx (voice box and vocal chords) are irritated or injured. Examples of causes of hoarseness include: laryngitis, straining the vocal cords by yelling or screaming, infections, GERD, allergies, and more. Treatment of hoarseness depends on the cause.
Schatzki (Schatzki's) ring, is a narrow ring of tissue located just above the junction of the esophagus and stomach. The cause of Schatzki ring is not clearly known, however, some doctors believe they are caused by long term acid reflux. The symptoms of a Schatzki ring is primarily poorly chewed food that stays in chunks becoming stuck in the esophagus. Diagnosis of Schatzki's ring is barium x-ray or endoscopy. Treatment is generally a procedure to stretch or fracture the rings.
Though it's difficult to say why some people develop cancer while others don't, research shows that certain risk factors increase a person's odds of developing cancer. These risk factors include growing older, family history of cancer, diet, alcohol and tobacco use, and exposure to sunlight, ionizing radiation, certain chemicals, and some viruses and bacteria.
Heartburn is a burning sensation experienced from acid reflux (GERD). Symptoms of heartburn include chest pain, burning in the throat, difficulty swallowing, the feeling of food sticking in the throat, and a burning feeling in the chest. Causes of heartburn include dietary habits, lifestyle habits, and medical causes. Treatments for heartburn include lifestyle changes, OTC medication, prescription medication, and surgery.
Acid backing up into the larynx (voice box), it causes reflux laryngitis. Irritation of the lining of the esophagus, larynx, and throat can lead to esophagitis, sinusitis, strictures, hoarseness, throat clearing, swallowing problems, asthma, chronic cough, and more. Typical symptoms of reflux laryngitis include heartburn, hoarseness, or a sensation of a foreign body in the throat. Reflux laryngitis can be treated with OTC medication, prescription medication, and lifestyle changes.
Disease prevention in men includes routine screening tests that are part of basic prevention medicine. Take an active role in your own health care and discuss screening tests with your doctor early in life. Age of screening and timing of screening depends upon the condition being assessed.
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