Barrett's oesophagus

Question 1

Define Barrett’s oesophagus.

Answer 1

Change in the normal squamous epithelium of the oesophagus to specialised intestinal metaplasia.

Associated with GORD, even if reflux is asymptomatic. Histology will show columnar-lined epithelium with or without intestinal metaplasia and with goblet cells.

Question 2

What is the main concern with Barrett’s oesophagus?

Answer 2

Main concern is progression to adenocarcinoma of the oesophagus.

Question 3

How common is Barrett’s?

Answer 3

• Affects 0.5-2% of the population, increasing incidence
• In people with reflux - 8% have Barrett’s
• In asymptomatic individuals - 6% have Barrett’s
• 25% are <50years old

Question 4

What are the risk factors for Barrett’s?

Answer 4

• Acid/bile reflux or GORD
• Increased age
• White ethnicity
• Male sex
• FH of Barrett’s oesophagus/oesophageal adenocarcinoma
• Obesity
• Smoking

Question 5

What is the difference between metaplasia and dysplasia in Barrett’s?

Answer 5

(1) Metaplasia = not pre-malignant because reversible

(2) Dysplasia = changes showing some of the cytological + histological features of malignancy but with no invasion through the BM

• Low grade
• High grade

Question 6

What are the types of Barrett’s oesophagus?

Answer 6

Squamous → Columnar METAPLASIA

1. Without goblet cells: gastric metaplasia
2. With goblet cells: intestinal type metaplasia

Question 7

What is the typical presentation of Barrett’s?

Answer 7

• Presence of risk factors
• Heartburn
• Regurgitation
• Dysphagia
• Belching (burping)
• Burning on swallowing hot drinks/alcohol

Other:

• Chest pain
• Laryngitis
• Cough
• Dyspnoea/wheezing
• History of aspiration pneumonia

Question 8

What are the signs of Barrett’s on examination?

Answer 8

• Normal or
• Wheeze on auscultation
• Epigastric pain

Question 9

What investigation would you do for Barrett’s oesophagus?

Answer 9

• OGD with biopsy - abnormal epithelium characteristic of Barrett’s oesophagus. Reveals columnar-lined epithelium with goblet cells, with or without dysplasia.
• Barium oesophagogram - identifies hiatal hernia and reflux

Question 10

What else should be recorded during endoscopy and what is the classification for Barrett’s?

Answer 10

Length of Barrett’s (short if <3cm) and dysplasia degree

Prague C&M classification - reproducible description of the extent of Barrett’s. Uses assessment of the circumferential (C) and maximal (M) extent of the endoscopically visualised segment of Barrett’s

Question 11

How do you manage Barrett’s?

Answer 11

Non-dysplastic:

Monitoring - every 5yrs if <3cm, every 5yrs if _>_3cm

Medical - PPI plus surveillance at least every 2 years.

Dysplastic:

Low grade:

• Surveillance 6monthly then less frequent
• Endoscopic eradication

High grade: 20-40% risk of harbouring adenocarcinoma

• Endoscopic eradication or mucosal dissection for complete resection
• Radiofrequency ablation
• Surveillance after treatment

Question 12

What are the complications of Barrett’s?

Answer 12

• Dysplasia and adenocarcinoma
• Oesophageal stricture
• Low QOL- depression, anxiety, stress

Question 13

What is the prognosis in Barrett’s?

Answer 13

Prognosis:

• Good with surveillance (every 5 years if non-dysplastic). 5 year survival with detected adenocarcinoma is >85%.
• PPIs do not cause regression of Barrett’s even with aggressive acid suppression but only ~0.4% progress to adenocarcinoma.
• Anti reflux surgery can cause regression of Barrett’s in 25% and lowers the risk of progression to adenocarcinoma.