Warning: This page contains photos of the human esophagus. These are graphic photos that may not be suitable for viewing by all individuals. Discretion is advised.
What Is Barrett's Esophagus?
After swallowing, liquids and solid foods travel from the mouth to the stomach through a tube-shaped organ called the esophagus. The inside surface of the normal esophagus is covered by a pearly-white lining made up by cells similar to those that cover the skin. These cells are called squamous cells. In Barrett's esophagus (also called Barrett's metaplasia), the normal pearly-white lining is replaced by a pink-red velvety lining made up by cells called specialized columnar cells. They look like the cells that line the inner surface of the colon, and include a very characteristic cell type called "goblet cell."
Warning: This page contains photos of the human esophagus. These are graphic photos that may not be suitable for viewing by all individuals. Discretion is advised. View photos.
What Causes Barrett's Esophagus?
It is caused by repeated episodes of acid reflex, known as gastroesophageal reflux disease (GERD). Normally the juices of the stomach do not go back into the esophagus. However, in some people this can occur, and because the normal cells which line the inner surface of the esophagus are not resistant to the stomach juices, they get inflamed, causing these individuals to have a "heart burn."
Why Should I Care About Barrett's Esophagus?
Patients who have Barrett's esophagus are at a greater risk for developing cancer of the esophagus, ulcers in the esophagus, narrowing of the esophagus tube so they will have problem swallowing the food, and most importantly cancer. Patients who have Barrett's esophagus have increased odds (risk) for getting a special type cancer in the esophagus than people who do not have Barrett's esophagus. This type of cancer is called "adenocarcinoma." This type of cancer has been affecting more and more people every year. It is the fastest rising cancer in white Caucasian men in the United States. Most patients with this cancer die within two years of diagnosis, but survival for as long as 10 years (and even cure) can be achieved if the cancer is discovered in its early stage, and removed by surgery.
Who Is at Risk of Developing Barrett's Esophagus?
Barrett's esophagus is estimated to affect about 700,000 adults in the U.S. Individuals with symptoms of GERD (for example, heartburn, acid regurgitation, sour taste in the mouth) are at an increased risk of developing Barrett's esophagus. Individuals older than 50, especially Caucasian men, are at high risk. Barrett's esophagus also occurs in Caucasian women, and in African Americans and Hispanics. Others groups at risk include obese individuals, those with a large waist circumference, smokers, and anyone with a family history of reflux or esophageal cancer.
What Happens if I Have Barrett's Esophagus?
Approximately 80 percent of patients with esophageal adenocarcinoma removed by surgery when the cancer is discovered at an early stage live for at least five years. Unfortunately, in most patients cancer is discovered at a late stage, and of these patients less than 25 percent survive three years after surgery. It is important, therefore, to be able to detect this cancer when it is still at an early stage. Best survival can be expected when the cancer is still in the lining of the esophagus. Once the cancer gets into the muscle of the esophagus, chances of long term survival are greatly diminished. This is the reason why it is important that patients with Barrett's be examined by a specialized doctor, a gastroenterologist, at regular time intervals (endoscopic surveillance) so if they get cancer it can be removed early to increase their chances of living longer.
What Is Endoscopic Surveillance?
It is strongly recommended that patients with Barrett's esophagus are examined by a gastroenterologist, a specialized doctor, at regular time intervals (endoscopic surveillance) so if they get cancer it can be removed early to increase their chances of living longer.
This examination include inserting a tube into the patient's esophagus (endoscopy) to examine it closely, and to get pieces of tissue (biopsy) from it which are then sent to a pathology laboratory for examination.
The picture to the right shows how Barrett's metaplasia looks through the endoscope. The black hole seen off-center is where the stomach is. "S" is the remaining squamous lining of the esophagus, with its shiny pearly-white appearance. "B" is patches of pink-appearing Barrett's metaplasia.
Warning: This page contains photos of the human esophagus, surgically removed following the diagnosis of Barrett's metaplasia and cancer. These are graphic photos that may not be suitable for viewing by all individuals. Discretion is advised. View photos.
What Is Done at the Pathology Laboratory?
The pathologist looks at very thin sections of the tissue biopsy under the microscope to determine if there is cancer, in which case the patient would be advised about surgery. The pathologist also looks for tissue changes called "dysplasia," then report the absence or presence of dysplasia, in the degree of dysplasia.
What Is Dysplasia?
This is a simplified explanation to a complex thing. Uncomplicated Barrett's tissue looks under the microscope like the picture on the right. The circle-shaped structure is called a "gland." This gland is formed by epithelial cells lined side by side surrounding a space at the center of the gland called "lumen." The blue dots at the base of the cells are the nuclei (pleural of nucleus) which usually are regular in shape and size, so they do not differ much from on cell to the next, sitting at the base of each cell opposite from the luminal space. With "dysplasia" (the right picture) the nuclei become darker in color, then become larger and different from one cell to the other, they are crowded, and can bee seen anywhere in the cell including close to the luminal space side of the cells. Patients with Barrett's in whom dysplasia is detected in the biopsy are at higher risk for cancer than those without dysplasia, and therefore they are followed up with endoscopy more frequently.
Dysplasia has two grades. A low grade and a high grade (which is worse), and sometimes it is difficult to tell with confidence if dysplasia is really there. Inflammation, which is not infrequent in Barrett's, can cause changes in the tissue very similar to dysplasia. In these cases when the pathologist is not sure whether there is dysplasia or not, the case is called "indefinite" or "indeterminate" for dysplasia.
Unfortunately, pathologists differ significantly in their diagnosis of dysplasia. Some cases called free of dysplasia by one pathologist may be called positive for dysplasia by another, and the opposite is true. For this reason, an expert pathologist is required to confirm the diagnosis. Researchers including our group, are working on alternative methods of determining cancer risk in patients with Barrett's.
What Are the Treatment Options for Barrett's Esophagus and Early Esophageal Adenocarcinoma?
Treatment options for Barrett's esophagus depend on several factors including the presence or absence of hiatal hernia, extent of Barrett's metaplasia, presence and severity of dysplasia, as well as physical fitness of the patient. These options, which are all available at the Baylor Clinic include dietary modifications, medications to suppress stomach acid secretion, local ablation therapy directed at Barrett's metaplasia (such as radio frequency ablation (BARRX) – (See Figure B), cryoablation, and endoscopic mucosal resection (See Figure A).
Left: This picture shows two small early esophageal cancers (C) arising in Barrett's esophagus.
Center: This picture shows endoscopic mucosal resection (EMR) where the cancer is removed via endoscopy by one of our gastroenterologist at the Baylor Clinic Barrett's Esophagus Center.
Right: This picture shows the esophagus of the same patient in the previous two pictures following removal of cancer using EMR.
We also perform an advanced procedure called endoscopic where areas of Barrett's esophagus complicated with dysplasia as early cancer get removed endoscopically. Mucosal resection (EMR) - (See Figure B, photodynamic therapy and laser), and surgery including laparoscopic surgery. These now should be discussed with the gastroenterologist following proper clinical evaluation.
Left: This picture shows a very long segment of Barrett's esophagus (B) involving almost the entire esophagus with only few remaining normal islands of mucosal (N).
Center: This picture shows the BARRX procedure for ablating Barrett's esophagus performed by a gastroenterologist in the Baylor Clinic Barrett's Esophagus Center.
Right: This picture shows the esophagus following BARRX ablation from the same patient shown in the previous two pictures. There is almost complete removal of abnormal Barrett's epithelium and replacement with normal epithelium.
What Are the Advantages of Consulting with the Barrett's Esophagus Center at Baylor College of Medicine?
At the Barrett's Esophagus Center, we offer a wide spectrum of services that are part of our comprehensive approach from diagnosis to treatment for patients with Barrett's Esophagus. Our patients receive check ups tailored to their needs and based on the latest practice guidelines. We also offer our patients the benefit of enrolling in ongoing clinical trials, as well as regular updates on the latest Barrett's esophagus research.
See Services for more information.