Barrett's Esophagus (cont.)
In this Article
Why is it important to screen patients with GERD to diagnose Barrett's esophagus?
Unfortunately, most cancers of the esophagus are
detected too late to be treated effectively. By the time cancer-related symptoms
of chest pain, weight loss, and progressive difficulty in swallowing (dysphagia)
lead to the diagnosis, the cancer has already spread beyond the esophagus to
other organs. Indeed, there is evidence that survival is markedly improved in
cancers detected during the course of surveillance for dysplasia or cancer in
Barrett's esophagus as compared with survival in cancers detected after cancer
symptoms prompted medical attention. Therefore, physicians want to make the diagnosis of Barrett's in GERD patients and then begin surveillance for cancer in such patients.
The problem, however, as mentioned previously, is that only 5% of all patients with adenocarcinomas of the esophagus or cardia have had an endoscopy to show that they have Barrett's esophagus. Thus, the challenge is to identify those GERD patients who have Barrett's by screening patients with chronic GERD. Yet, sufficient research has not been done to establish guidelines for selecting which patients with GERD should be screened by endoscopy.
For now, until more data becomes available, it seems reasonable that if a patient with GERD cannot be taken off acid suppressing drugs after
two to three years (because of persistent symptoms), an endoscopy should be done to see if Barrett's esophagus is present. One endoscopy per lifetime in patients with GERD may be sufficient to screen for Barrett's.
Why is it critical to be accurate in the diagnosis of Barrett's esophagus?
When a patient is referred for endoscopy in which screening for Barrett's esophagus is to be done, it is important that any inflammation or ulcerations first be healed with the help of acid-suppressing drugs given for at least
six weeks. Most commonly this is a double daily dose of a PPI. There are two reasons to eliminate the inflammation first before diagnosing Barrett's. One is that Barrett's can be hidden beneath the inflamed, ulcerated lining. The second is that the changes that occur with inflammation of the esophageal lining may mimic dysplasia and, therefore, may lead to a falsely positive diagnosis of dysplasia.
In the initial diagnosis of Barrett's esophagus, the endoscopist (the doctor performing endoscopy) needs to provide the pathologist with three landmarks so that a precise diagnosis of Barrett's can be made.
- One is the location of the lower esophageal sphincter
(LES) or gastroesophageal junction.
- The second is the upper end of the squamo-columnar junction (Z line),
which now (with Barrett's) is in the esophagus (moved north).
- The third is the location of the biopsies.
The reason that such precise descriptions need to be made is because a false positive diagnosis of Barrett's may have serious implications. Thus, the diagnosis of Barrett's esophagus can lead to higher cost of obtaining life, health, and disability insurance, or sometimes difficulty in getting insurance at all. On the other hand, it's important to know when Barrett's is, in fact, present so that the patient can be enrolled in a proper surveillance program.
If the diagnosis of Barrett's esophagus is uncertain or equivocal, it is worthwhile obtaining a second opinion with specialists in a center that has extensive experience with Barrett's. There are at least three reasons for obtaining additional consultation:
- To avoid concern about long term cancer risk if the
diagnosis of Barrett's was incorrectly made.
- To avoid difficulties with insurance that may arise with an incorrect diagnosis of Barrett's esophagus.
- To begin cancer surveillance if the diagnosis of Barrett's is confirmed.
Next: What does endoscopic biopsy surveillance in Barrett's esophagus involve? »
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