Barrett's oesophagus

Barrett's oesophagus

Barrett's oesophagus is a condition in which abnormal cells develop on the inner lining of the lower part of the gullet (oesophagus). The oesophagus is the muscular tube that carries food from the mouth to the stomach.

Barrett's oesophagus is not in itself a cancerous condition, but over a period of time it can occasionally lead to cancer developing in the lower part of the oesophagus. A cancer happens when cells in the affected area continue to grow and reproduce and become increasingly abnormal. Approximately 1–2 out of every 200 people in the UK have Barrett's oesophagus; however, very few people with this condition go on to develop cancer (about 1 in 100 each year).

The digestive system

Causes

The main cause of Barrett's oesophagus is juices from the stomach 'splashing' up into the oesophagus. The stomach produces acid, and the stomach juices also contain bile and proteins, which help to digest food. The stomach is lined by tissue that is resistant to acid, but the oesophagus is not. Normally, a valve at the bottom of the oesophagus prevents acid from splashing up into the gullet. However, some people have a weak valve, which allows the acid to flow backwards into the oesophagus. The acid may inflame and irritate the oesophagus, and, in some people, will cause symptoms of pain and heartburn. This is often referred to as reflux oesophagitis.

Certain factors can make people more likely to have reflux, and these include being overweight, smoking, and excessive alcohol consumption. For some people, spicy, acidic, or fatty foods can cause reflux. Reflux is often also caused by a small piece of the stomach being displaced and poking through the sheet of muscle which divides the chest from the abdomen (a hiatus hernia).

The pre-cancerous changes in the cells are also sometimes called dysplasia. Dysplasia can be either low-grade, or high-grade depending upon how abnormal the changes are, with high-grade being the most abnormal.

Signs and symptoms

Some people have no symptoms at all and the Barrett's oesophagus is discovered during tests for other medical conditions. The most common symptom is ongoing heartburn and indigestion. Other symptoms include feelings of sickness (nausea), being sick (vomiting) and difficulty swallowing food. Less commonly, there may be blood in the vomit or stools (bowel motions). Some people have pain on swallowing food.

If you have any of these problems on a regular basis, it is advisable to visit your GP.

How it is diagnosed

Your GP will examine you and may refer you to the hospital for a procedure known as an endoscopy to examine the lining of your oesophagus.

The endoscopy may be carried out by a doctor or specialist nurse, and enables the oesophagus to be examined using a thin flexible tube called an endoscope. If necessary, small samples of cells are taken, which can then be examined in a laboratory to see if they are normal (biopsy).

You can usually have an endoscopy as an outpatient, but occasionally an overnight stay in hospital is necessary. Once you are lying comfortably on the couch, you may be given a local anaesthetic spray to numb the back of your throat, and reduce any discomfort during the test. Alternatively, you may be given a sedative to make you feel sleepy. The sedative is usually injected into a vein in the arm. The doctor or nurse then passes the endoscope down your oesophagus.

An endoscopy can be uncomfortable but it is not painful. After a few hours the effect of the sedative or anaesthetic will wear off and you will be able to go home. You should not drive for several hours after the test and, if possible, you should arrange for someone to travel home with you. You should not try to swallow anything for several hours, until the local anaesthetic has worn off. Some people have a sore throat afterwards; this is normal and usually disappears after a couple of days. If it does not, it is advisable to contact your doctor at the hospital. You should also tell your doctor if you have any chest pain, breathlessness or blood in your vomit.

Surveillance

Often, people with Barrett's oesophagus are advised to have their condition checked at regular intervals in order to pick up any further changes. This is known as surveillance and usually involves regular endoscopies and biopsies. At present, it is not known how useful surveillance is. This is because of the small number of people with Barrett's oesophagus who actually go on to develop oesophageal cancer. It will be some time before the benefits and possible disadvantages of regular endoscopies become clear.

Depending on the degree of change in your condition, if any, and the policy at your hospital, the endoscopies may be repeated at intervals between 3 months and 3 years.

It may be helpful to discuss this with your specialist.

If you are having regular endoscopies and you notice any change or worsening of your symptoms between appointments, it is a good idea to contact your specialist.

Treatment

Lifestyle changes

Sometimes it is possible to reduce the reflux without treatment. Losing weight (if necessary), stopping smoking, or drinking less alcohol may help. Eating small meals at regular intervals, or avoiding foods that aggravate the symptoms, can also help to reduce reflux. If you suffer with reflux at night, it can help to raise the head of the bed.

Medicines to reduce acid

You may be given medicines such as proton pump inhibitors (PPI), or histamine receptor blockers to decrease the production of stomach acid. This will help to reduce any symptoms that you have. Once the symptoms are controlled, the dose of your PPI may be reduced to a level that keeps the symptoms from recurring. PPIs are often taken for life, and are very safe to take long-term.

Surgery

Surgery can be carried out to help strengthen the valve at the bottom of the oesophagus, to prevent further acid reflux, or to remove the affected area.

Strengthening the valve Strengthening the valve at the bottom of the stomach usually involves surgery, performed through a small cut made in the skin of the chest (keyhole surgery). You may need to stay in hospital for a few days and will have several small cuts in the area after the surgery, which heal over after a few days. Occasionally, it may be possible to strengthen the valve during an endoscopy. An electrical current can be passed through the valve, and tighten it. This does, however, cause scarring. Alternatively, stitches can be placed in the valve or it can be injected with a substance that helps it to tighten.

An operation known as fundoplication is another way of strengthening the valve at the bottom of the oesophagus. During the operation, the top of the stomach (the fundus) is wrapped and sutured around the lower end of the oesophagus. This procedure reinforces the lower end of the oesophagus, and should help to reduce acid reflux. Fundoplication may involve a large incision in the abdomen (a laparotomy) or it can be done using a laparoscope, which will only involve small cuts in the abdomen.

An operation to repair a hiatus hernia may also help to reduce acid reflux.

Removing the affected area If a biopsy shows that there are continuing changes in the cells lining the lower end of the oesophagus that may progress to cancer, your specialist may suggest that you consider having surgery to remove the affected area, or other treatments that can destroy the abnormal cells. Treatments to destroy these cells include photodynamic therapy and cold coagulation (see below).

Surgery involves removing the section of the oesophagus that contains the abnormal cells. The stomach is then joined to the remaining length of the oesophagus. After your operation, you are likely to spend a short period of time in the intensive care unit. You will have a drip put into a vein in your hand or arm until you are able to eat and drink again. You may also have a fine tube (a nasogastric (NG) tube) that passes down your nose and into your stomach, or small intestine, inserted, to allow any fluids to be removed. This will stop you feeling sick. It also helps the area of the operation to heal. You may feel afraid to swallow for a short time, and may have a bad taste in your mouth. Mouthwashes can help to relieve this.

At first, you will probably be given only sips of liquid until your doctor is satisfied that the join in the oesophagus is healing. It will be a few days before you are able to drink normally. Gradually, you will also be able to eat normally again.

Some surgeons will also place a small feeding tube directly into the small bowel at the time of surgery, to feed you while you recover. This is usually removed after you have started to swallow normally.

Sometimes, surgery to remove only the affected area of the lining of the oesophagus may be carried out during endoscopy. This type of surgery is known as endoscopic mucosal resection and can be used as a treatment, or to help with diagnosis. It is a smaller operation than the surgery mentioned above, and you will need a few days to recover from it. This type of surgery may be followed by photodynamic therapy or endoscopic treatments (see below).

Endoscopic Treatments

Photodynamic therapy is only done in specialist centres. Photodynamic therapy uses laser light combined with a light-sensitive drug (sometimes called a photosensitising agent) to destroy the abnormal cells. Doctors are still researching how useful photodynamic therapy may be in treating Barrett's oesophagus. Your specialist can advise whether or not this treatment is appropriate in your situation.

Other endoscopic techniques As well as PDT, there are some newer techniques that doctors are currently looking at. These include: cold coagulation, argon plasma coagulation, radiofrequency ablation, multipolar electro coagulation and endoscopic plication. Your specialist can tell you more about these approaches and whether any of them might be appropriate in your situation. It is important to remember that these techniques are not widely available.

Your feelings

It is often difficult to find information and support when you are diagnosed with a condition such as Barrett's oesophagus. You may have concerns about whether or not you need surveillance, medication, or perhaps an operation. It is important to discuss these concerns with the doctors and nurses caring for you.

You may have many different emotions including anxiety and fear. These are all normal reactions, and are part of the process that many people go through in trying to come to terms with their condition. Many people find it helpful to talk things over with their doctor or nurse. Close friends and family members can also offer support.

References

This section has been compiled using information from a number of reliable sources including:

• Oxford Textbook of Oncology (2nd edition). Eds Souhami et al. Oxford University Press, 2002.
• Cancer and its Management (4th edition). Eds Souhami and Tobias. Oxford Blackwell Scientific Publications, 2003.
• The Textbook of Uncommon Cancers (2nd edition). Eds Raghavan et al. Wiley, 1999.
• Guidance on the Use of Proton Pump Inhibitors in the Treatment of Dyspepsia. National Institute of Clinical Excellence (NICE), June 2000.

For further references, please see the general bibliography.

Via: http://www.cancerbackup.org.uk