Barrett's Esophagus (cont.)
In this Article
What is the risk of adenocarcinoma of the esophagus in Barrett's?
When looking at Barrett's esophagus patients as a whole group, the risk of
cancer has been found to be as low as 1 in 300 patient-years. This means that if
we examined 300 patients yearly, one patient would be found to have cancer every
year. What we really need to know, however, is something that's a bit
different. That is, it would be even more helpful to know what the risk of
cancer would be if someone with Barrett's is found to have NO DYSPLASIA after
1 or 2 years of surveillance. Our belief is that this risk would be much less
than the above-quoted figures of 1 in 300 patient-years.
If a patient has high grade dysplasia and a biopsy is done within 3 months,
up to about 50% of these patients may be found to have cancer. Also, we know
that high grade dysplasia is associated with a greater immediate or short term
risk of cancer, which ranges from 15% up to more than 50% in the published
literature. Therefore, the first order of management when high grade dysplasia
is found is to rule out the possibility that it points to the coexistence of an
adenocarcinoma.
Low grade and indefinite dysplasia are much less threatening than high grade
dysplasia, but we don't know just how much less. In fact, we don't have
precise data to indicate just what the cancer risk is in Barrett's patients
with low grade or indefinite dysplasia.
The diagnosis of dysplasia should be as certain and precise as possible
because this diagnosis can prompt a change in the treatment or the intensity of
follow-up of patients with Barrett's esophagus. Moreover, it takes a great
deal of experience to be able to make a precise diagnosis of the presence or
specific grade of dysplasia. Therefore, especially if a change in the routine
management of Barrett's is contemplated, it is a common and useful practice to
ask a second pathologist (or even a third, if necessary) to review the biopsies.
The idea is to see if there is agreement between the pathologists and/or to get
a more experienced opinion about the presence and grade of dysplasia.
If a person has a longer segment Barrett's, one would guess that the cancer
risk is greater. The data, however, is controversial in this regard. For that
reason, the current practice is to do endoscopic biopsy surveillance with
similar frequency in patients with short and longer segment Barrett's
esophagus.
What are the symptoms of Barrett's esophagus?
Barrett's esophagus has no unique symptoms. Patients with Barrett's have
the symptoms of GERD (i.e., heartburn, regurgitation of fluid, nausea, etc.).
The general trend is for Barrett's patients to have more severe GERD. However,
not all Barrett's have marked symptoms of GERD, and some patients are detected
almost accidentally with minimal symptoms of GERD.
Heartburn is a burning sensation behind the breastbone, usually in the lower
half, but which may extend all the way up to the throat. Sometimes, it is
accompanied by burning or pain in the pit of the stomach just below where the
breastbone ends. The second most common symptom is regurgitation (backup) of
bitter tasting fluid. GERD symptoms are often worse after meals and when lying
flat.
The refluxed, regurgitated fluid may involve the lungs or voice box (larynx)
and thereby produce what is called the extraesophageal (outside the esophagus)
symptoms (manifestations) of GERD. These symptoms include new onset adult
asthma, frequent bronchitis, chronic cough, sore throats, and hoarseness. For
reasons we don't understand, some GERD patients have minimal heartburn but
experience other GERD symptoms (e.g., regurgitation of bitter tasting fluid or
even the extraesophageal symptoms) that are more dominant in either frequency
and/or severity.
Other clinical features of GERD are due to strictures and ulceration of the
esophagus. A stricture is a scarring (fibrosis) of the esophagus that may cause
difficulty swallowing (dysphagia). The dysphagia is sensed as a sticking
(stopping) in the chest (actually in the esophagus) of solid food, or even
liquids when the dysphagia is severe. Strictures must be treated by stretching
them at endoscopy with dilators. Untreated, strictures may promote more spillage
of food and/or gastric fluids into the lungs. Not commonly seen in GERD is
massive gastrointestinal (GI) bleeding that is caused by inflammation of the
esophagus. Such massive GI bleeding would result in vomiting blood or passing
black or maroon stools. More commonly, however, an inflamed esophagus can cause
slow bleeding that is detected when anemia (low blood) is found and/or stools
are tested chemically for blood.
Next: How is GERD treated, with or without Barrett's esophagus? »
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