BARRETT'S ESOPHAGUS: TREATMENT

Barrett's esophagus is a change in the lining of the lower esophagus, caused over years by acid reflux. The normal lining is replaced by one resembling the lining of the intestine. It is not cancer. In a small proportion of people it is a precursor, meaning the cells can gradually change over time and eventually become esophageal cancer.

What happens next depends almost entirely on one thing: whether the cells show dysplasia, and if so, to what degree.

The three grades, and what each one means

Dysplasia describes how abnormal the cells look under the microscope. It is graded by a pathologist from biopsies taken at endoscopy.

No dysplasia. The lining has changed, but the cells themselves are not abnormal. The risk of progressing to cancer is low, well under 1 in 100 per year. No procedure is needed. Management is acid-suppressing medication and a check endoscopy every 3 to 5 years — every 5 years for a short segment under 3 cm, every 3 years for a longer one.

Low-grade dysplasia (LGD). The cells show subtle abnormal changes under the microscope. This carries a slightly higher risk than no dysplasia, and so treatment is now usually recommended. In a randomized trial comparing “radifrequency ablation” with continued observation, the risk of progressing to high-grade dysplasia or cancer over three years was 1.5% with treatment versus 26.5% without. Continued close monitoring instead of treatment remains a reasonable choice for some people, and that decision is made together.

High-grade dysplasia (HGD). The cells are markedly abnormal when looked at under the microscope. This is the step immediately before cancer. Untreated, roughly 5 to 8 in 100 people per year go on to develop esophageal cancer. Treatment is recommended for essentially everyone fit for it.

An important point about grading: pathologists frequently disagree on these readings, particularly for low-grade dysplasia, and a substantial share of cases diagnosed in the community are reclassified when reviewed by a specialist pathologist at BIDMC. For that reason, your slides may be reviewed again, or we may take additional biopsies before any treatment is planned.

Why you have been referred

Most people referred to our advanced endoscopy team at BIDMC already have low-grade or high-grade dysplasia. People with Barrett's esophagus and no dysplasia are generally looked after by their own gastroenterologist with periodic endoscopy alone.

Being referred for treatment at BIDMC means there is an opportunity to remove the affected lining before anything further develops. This is a treatable, and usually curable, stage.

Treatment: what is involved

Treatment is not a single procedure. It is a sequence of endoscopies over several months, each building on the last, with the goal of eradicating every trace of the abnormal lining so that normal esophageal lining grows back in its place. Each procedure is done under deep sedation, endoscopically, without need for surgical incisions.

1. Careful inspection. The first step is a detailed endoscopy using high-definition equipment and special light filters that make subtle abnormalities visible. This can take longer than a standard endoscopy. The purpose is to map the segment precisely and to find any raised or irregular area — a nodule — that would change the plan. Areas easily overlooked on a routine examination are often found at this stage.

2. Repeat biopsies, and occasionally ultrasound. In some cases biopsies may be repeated, both from any visible abnormality and systematically along the whole segment, and reviewed by a pathologist specializing in this condition.

Endoscopic ultrasound — an endoscope with an ultrasound probe at its tip, imaging the wall of the esophagus from the inside, may be used in certain cases, mainly to evaluate a nodule or to check the nearby lymph nodes.

3. Removal of any visible nodule. Any nodule or raised area typically removed before we move on to any additional treatment. This serves two purposes at once: it removes the abnormal nodular tissue, and it provides a much larger tissue specimen than a biopsy, one that includes the deeper layers.

This step sometimes changes the picture. Examination of a resected specimen alters the diagnosis and treatment plan in about 30% of cases. Occasionally it reveals an early cancer that biopsies had not shown; more often it confirms that the abnormality is superficial and can be managed entirely endoscopically.

4. Radiofrequency ablation (RFA). Once any nodule has been removed and the remaining lining is flat, the rest of the Barrett's segment is treated with radiofrequency ablation. During your endoscopy, a device delivers a precisely controlled burst of heat to a very shallow depth of the esophagela lining, destroying the abnormal cells while leaving the deeper wall intact. Normal esophageal lining then regrows in its place.

This is the best-established of the ablation techniques, with the strongest supporting evidence, and is the preferred first choice in most cases.

Ablation takes several sessions. Ablation treatments typically occur at intervals of roughly 2 to 3 months. Most people need around 2 to 4 sessions; longer segments need more. Treatment continues until no Barrett's lining remains, confirmed by both appearance and biopsies.

How well it works

Well. In a national program of 1,384 patients treated with ablation with or without resection, complete eradication of Barrett's esophagus was achieved in 94%, and dysplasia recurred in only about 1% per year afterward. In the UK registry of over 2,500 patients, dysplasia was cleared in 88% within two years.

Risks. Chest discomfort/burning or difficulty swallowing for a few days after each session are common and expected. You will typically be advised to advance your diet slowly, starting with liquids. We will also send you home with prescriptions for medications which can soothe/calm the esophagus. Another risk fo the procedure is esophageal narrowing due to scar tissue, which can cause food to stick. This affects roughly 5 to 15 in 100 people and is treated by stretching the esophagus at a subsequent endoscopy. More severe complications including bleeding and esosphageal damage can occur but are very rare.

Cryotherapy and other alternatives

Cryotherapy is another technique we use, which destroys the abnormal lining by freezing rather than heating it — either by spraying liquid nitrogen onto the surface or by applying a cooled balloon.

It is considered mainly in three situations: when radiofrequency ablation has not fully cleared the segment, when the anatomy makes the radiofrequency device difficult to apply. Cryotherapy may require more sessions to reach the same endpoint, though chest discomfort afterward tends to be milder and shorter-lived.

Surgery to remove the esophagus was once the standard treatment for high-grade dysplasia. It is now rarely necessary, and is reserved for disease that endoscopic treatment cannot control or for cancer that has grown deeper than these techniques can reach.

After treatment is complete

Reaching the point where no Barrett's lining remains is the goal, but it is not quite the end. A small proportion of people develop recurrence, so endoscopy continues afterward — typically every 3 months during the first year, every 6 months in the second year, then annually. Most recurrences appear early, are picked up as a visible abnormality, and are treated successfully with a further session.

Acid-suppressing medication continues long term. It protects the newly regrown lining, and is generally taken indefinitely.

Living with it

Barrett's esophagus with dysplasia is one of the few precancerous conditions that can be found early, treated completely, and eliminated through the mouth, without an operation. The great majority of people treated this way never develop esophageal cancer.

Important lifestyle changes can reduce the risk of cancer development. Stopping smoking is always an important step. Weight loss helps reflux where excess weight is a factor. Keeping reflux controlled, with medications and by avoiding late meals, is sensible.

Between appointments, call about food sticking or difficulty swallowing, unintended weight loss, vomiting blood or black stools, or new persistent chest pain.

Suggested reading

The American College of Gastroenterology maintains plain-language patient information on Barrett's esophagus, including reflux management and what to expect from endoscopy: gi.org/topics/barretts-esophagus