Barrett's Esophagus

Barrett's Esophagus is a condition of the distal esophagus in which the normal mucosa is replaced by a different kind of lining. This is thought to be an adaptive response to protect from acid and bile. This is a pre-cancerous condition and requires regular endoscopic surveillance by a gastroenterologist. 

When the distal esophageal mucosa (inner lining) has been exposed to a large amount of acid and bile salts for a long time, the lining changes it's nature (metaplasia) to accommodate this hostile environment. These changes include the development of gastric (stomach) and intestinal type mucosa in the distal esophagus (specialized columnar epithelium). The distal esophageal mucosa that has undergone two stages of character change (gastric to intestinal metaplasia) has the potential to become malignant.

Risk Factors
The risk factors for Barrett's esophagitis are: hiatus hernia, incompetent lower esophageal sphincter, hyperacidity and acid reflux, and an incompetent pyloric sphincter. The latter  promotes bile reflux from the duodenum into the stomach and finally up to the esophagus. 

The risk factors for developing malignancy in BARRETT's esophagus are: 1) large hiatal hernia > 3cm, 2) length of Barrett's mucosa > 7cm, and 3) presence of dysplasia at the time of surveillance. 

Treatment
Treatment of Barrett's esophagitis is treatment of reflux related symptoms and signs. However Barrett's patients are in need of periodic surveillance to watch for developing malignancy. Neither the lack of reflux symptoms, nor the treatment of reflux through medical or surgical methods eliminate the need for this surveillance. We have seen three patients with Barrett's esophagitis associated with severe peptic esophagitis, which developed carcinoma during a short follow-up interval. The only other common denominator in all three was rapid healing of the peptic inflammatory process by a proton pump inhibitor. We have never seen progression or regression of the Barrett's lining with medical or surgical treatment of reflux. However, others have reported regression in patients with short segment Barrett's and no hiatal hernia. Laser ablation of the abnormal mucosa and endoscopic mucosectomy are amongst the new and promising therapeutic endeavors.