Barrett's Esophagus Symptoms, Causes, Treatment - What is the specific abnormality in the inner lining (epithelium) of Barrett's
esophagus? on MedicineNet
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.
What is the specific abnormality in the inner lining (epithelium) of Barrett's esophagus?
To repeat, the first criterion for the diagnosis of Barrett's esophagus is the finding at endoscopy of a pink lining in the esophagus where it is normally not seen. This abnormal lining may appear circumferentially like a band, tongue-like or as islands.. The second criterion is that biopsies from the pink lining reveal the characteristic intestinalized mucosa (the lining normally seen in the intestines) with the typical goblet cells.
The esophageal biopsies are obtained during an endoscopy. An upper gastrointestinal endoscopy is a procedure in which the doctor
inserts a long flexible tube (endoscope) through the mouth and down into the
esophagus to directly visualize the lining of the esophagus. During the same
endoscopic examination, the stomach and duodenum also can be visualized.
Multiple small samples (biopsies) of the lining epithelial tissue can be obtained through the endoscope.
Intestinal metaplasia
As mentioned previously, the process of the replacement
of one type of tissue lining by another is called metaplasia. In the stomach and
intestines, metaplasia is a common response to certain types of injury. As Henry
Appelman, a pathologist, stated: "When the gut is under stress it wants to be
something else." Other examples of metaplasia in which one lining replaces
another are: (1) in the stomach where chronic inflammation (gastritis) may
result in an intestinal-type lining replacing parts of the normal stomach
lining; and (2) in the duodenum (just beyond the stomach in the intestine) where
peptic ulcers occur and the intestinal lining surrounding the ulcer transforms into stomach-type lining.
We believe that the process of metaplasia is a protective or adaptive response to injury of the lining. However, the downside of metaplasia is that in Barrett's esophagus, it carries a small but definite increase in the risk of becoming cancerous. Not all metaplasias have an increased risk of cancer. For example, of the two metaplasias referred to in the previous paragraph, intestinal metaplasia in the stomach can lead to cancer, but intestinal metaplasia in the duodenum does not.
The process of developing Barrett's begins at the
junction of the stomach and esophageal linings. The esophagus normally is lined
by a squamous epithelium or lining layer. This squamous epithelium has a pearly
white appearance, whereas the lining in the stomach and intestines has a more
salmon pink color because it is a columnar epithelium rather than a squamous
epithelium. The squamous epithelium is made up of flat squamous cells, which are
similar to skin cells. The stomach or gastric lining consists of taller columnar
cells as seen under the microscope. The junction of the squamous epithelium of the esophagus and the gastric columnar epithelium occurs at the junction of the esophagus and stomach where, as you recall, the lower esophageal sphincter is located. The common border (interface) of these two linings is often referred to as the Z line, because when examined during an endoscopy, it has a zig zag appearance.
With progressive injury to the esophagus, metaplasia occurs and the metaplastic tissue moves up the esophagus for a distance which varies from person to person, usually from about 0.5 to 2.5 inches (about 1 to 6 centimeters). The type of cell that gives rise to the metaplastic tissue is not known.
Barrett's esophagus often is categorized into short- or long-segment Barrett's, based on the length of the esophagus that is affected. Short segment Barrett's generally refers to involvement of 3 centimeters or less while long segment means involvement of more than 3 centimeters of the esophagus. Interestingly, once Barrett's esophagus is diagnosed in a patient, the metaplastic lining does not seem to progress further up into the esophagus if the patient is being treated for GERD. Thus, over time, the length of involvement with Barrett's generally remains the same.
Intestinal metaplasia of the Z line (gastroesophageal junction) without
visible Barrett's
If biopsies are taken from patients with GERD who have a normal appearing Z line (no visible evidence of Barrett's esophagus), up to 30% will show the same intestinal type metaplasia with goblet cells as those that are seen in Barrett's esophagus. However, we do not routinely biopsy normal appearing Z lines to look for this change, nor do we do surveillance when we find it there. The reason is that limited intestinal metaplasia of the gastroesophageal junction region in GERD seems to occur with similar frequency in women and African Americans as in white men, yet the risk of overt Barrett's esophagus is much less than in white men.
Therefore, the presence of metaplasia on a routine biopsy of a normal appearing Z line in GERD should not lead to any change in management. What's more, the finding of goblet cells in this context should not be labeled, as some have suggested, as ultrashort segment Barrett's. The main reason for not labeling it as Barrett's is that the term Barrett's implies an increased risk of cancer, and there is no evidence that this finding is associated with an increased cancer risk.
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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