Barrett's oesophagus

Barrett's oesophagus is a condition where the cells of the oesophagus (gullet) grow abnormally. The oesophagus is the muscular tube that connects the mouth to the stomach. Barrett's oesophagus is not a cancer, but can develop into cancer in a very small number of people.

Acid reflux and GORD (gastro-oesophageal reflux disease) are the two main causes of Barrett's oesophagus. Acid reflux is when stomach acid splashes back into the oesophagus. GORD is when the acid irritates and inflames the oesophagus. Around 1 in 10 people with acid reflux (10%) will go on to develop Barrett's oesophagus.

The most common symptom of Barrett’s oesophagus is ongoing heartburn and indigestion.

To diagnose Barrett’s oesophagus doctors examine the oesophagus using an endoscope. A sample of cells (a biopsy) may also be taken for examination in a laboratory.

There are a number of options for treating Barrett’s oesophagus, which aim to reduce acid reflux and control symptoms. Making lifestyle changes and having medicines can reduce the amount of acid in your stomach. Other forms of treatment aim to remove or strengthen the affected area.

What is Barrett's oesophagus?

The oesophagus (gullet) is the muscular tube that carries food from the mouth to the stomach (see diagram below). In Barrett's oesophagus, there are changes in the cells on the inner lining of the oesophagus, at the lower end. Barrett’s oesophagus can affect men and women, although it is more common in men.

The cell changes in Barrett’s oesophagus can sometimes develop into something called dysplasia (also called precancerous). Dysplasia can be either low-grade or high-grade. In low-grade dysplasia, the cells are slightly abnormal. In high-grade, the cells are more abnormal.

Barrett's oesophagus is not itself a cancerous condition. However, over a period of time it can occasionally lead to cancer of the oesophagus.

Cancer develops 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 1–5 in every 100 people who have Barrett's oesophagus later develop cancer.

Upper digestive system
Upper digestive system

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Causes of Barrett's oesophagus

Acid reflux

This happens when the valve at the lower end of the oesophagus is weak and allows stomach contents to splash up into the oesophagus. Reflux of acid is very common and many people have symptoms at some point in their lives.

Certain factors can make people more likely to have reflux. These include:

  • being overweight
  • smoking
  • drinking too much alcohol
  • eating spicy, acidic, or fatty foods.

Acid reflux can also be caused by a hiatus hernia. A hiatus hernia is when a small piece of the stomach is displaced and pokes through the diaphragm. The diaphragm is the sheet of muscle that divides the tummy area from the chest.

GORD (gastro-oesophageal reflux disease)

This is when stomach acid irritates the oesophagus. The stomach produces acid to help digest food. While the stomach is lined by tissue that’s resistant to acid, the oesophagus isn't. In some people, the acid can inflame and irritate the oesophagus, causing pain and heartburn. This is often referred to as gastro-oesophageal reflux disease (GORD) or reflux oesophagitis.

Not everyone who has acid reflux will develop Barrett's oesophagus. Up to 1 in 10 people with acid reflux (10%) will develop Barrett's oesophagus. It is more likely to happen in people who’ve had severe reflux for many years. It’s also more likely in people over 50, and in men.


Signs and symptoms of Barrett’s oesphagus

Some people have no symptoms at all and Barrett's oesophagus is found during tests for other medical conditions.

The most common symptom is ongoing heartburn and indigestion. Other symptoms include feeling sick (nausea), being sick (vomiting) and difficulty swallowing food. Less commonly, there may be blood in the vomit. Some people have pain when swallowing food.

If you experience any of these problems for more than two weeks, or if you ever vomit blood, you should visit your GP.


How Barrett’s oesophagus is diagnosed

Endoscopy

Your GP will examine you and may refer you to the hospital for an endoscopy. This is a procedure to examine the lining of your oesophagus. Endoscopies can also be used to give treatment.

A doctor or specialist nurse will do the endoscopy. It involves examining the oesophagus using a thin, flexible tube called an endoscope. Usually, small samples of cells (biopsies) are taken. These are then examined in a laboratory.

You can usually have an endoscopy as an outpatient. Occasionally, an overnight stay in hospital is needed. You will lie on a couch on your side for the endoscopy. You may be offered a local anaesthetic spray to numb the back of your throat and reduce discomfort during the test, or a sedative to make you feel sleepy. The sedative is usually injected into a vein in your arm. The doctor or nurse then passes the endoscope down your oesophagus.

An endoscopy can be uncomfortable but it isn't painful. After a few hours, the effect of the sedative will wear off and you'll be able to go home.

If you've had the anaesthetic sprayed onto the back of your throat, you may need to stay in hospital until it has worn off. This usually takes about 1–2 hours. You shouldn't try to swallow anything during this time. The nurse or doctor will tell you how long to wait before you try to swallow anything.

If you’ve had a sedative, you shouldn't drive for several hours after the test. If possible, you should arrange for someone to travel home with you. Some people have a sore throat following the procedure. This is normal and usually disappears after a couple of days. If it doesn't, 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 monitored. This means checking at regular intervals for any further changes in the cells. It is known as surveillance and usually involves regular endoscopies and biopsies. Currently, it's not known how useful surveillance is. It will be some time before the benefits and possible disadvantages of regular endoscopies become clear.

You may have endoscopies at intervals ranging from every three months to every three years. This will depend on whether your condition is changing, the degree of change, and your hospital’s policy. You may find it helpful to discuss this with your specialist.

If you're having regular endoscopies and you notice any changes or your symptoms get worse between appointments, contact your specialist.


Treatment for Barrett’s oesophagus

Treatment for Barrett’s oesophagus aims to reduce acid reflux and control symptoms.

Research is ongoing into new ways to diagnose and treat Barrett’s oesophagus.

Lifestyle changes

Sometimes, it's possible to reduce acid reflux by making some lifestyle changes. Losing weight (if necessary), stopping smoking and drinking less alcohol may help. Eating small meals at regular intervals, and avoiding foods that aggravate your symptoms can also help. Have your last meal of the day 2–3 hours before bedtime and avoid late night snacks if possible. This is because eating encourages the stomach to produce more acid, which can cause you to have reflux at night. If you do have reflux at night, it can help to raise the head of the bed.

Medicines to reduce acid

You may have medicines to decrease the production of stomach acid. These include proton pump inhibitors (PPI) or histamine receptor blockers. This will help reduce the symptoms of Barrett’s oesophagus. Once the symptoms are controlled, the dose of your PPI may be reduced to a level that stops the symptoms from recurring. PPIs are often taken for life, and are very safe to take over a long time.

Fundoplication

This is an operation to strengthen the valve at the bottom of the oesophagus. During the operation, the top of the stomach (the fundus) is wrapped and stitched around the lower end of the oesophagus. This strengthens the lower end of the oesophagus, and should help reduce acid reflux. Fundoplication is often done using keyhole surgery. This means the surgeon uses a laparoscope to make a few small cuts in the abdomen, rather than one large opening. Sometimes. it does involve a large incision in the abdomen (a laparotomy).

Repairing a hernia

An operation to repair a hiatus hernia may also help to reduce acid reflux. Very occasionally, a hiatus hernia can affect the chest area (known as a complicated hiatus hernia). In this situation, a chest operation may be necessary.

Removing the affected area

If a biopsy shows that there are continuing changes in the cells, which may progress to cancer (dysplasia), your specialist may suggest treatment to remove the affected area. There are two main approaches – endoscopic mucosal resection and surgical resection.

Endoscopic mucosal resection

The aim of this surgery is to remove only the affected area of the oesophagus lining, without damaging the rest of the oesophagus. It's done using an endoscopy. It can be done as a day case under sedation, or during an overnight stay. This type of surgery may be followed by other endoscopic treatments.

Surgical resection

Sometimes, more extensive surgery is needed. The surgeon will remove the section of the oesophagus that contains the abnormal cells. The stomach is then joined to the remaining part of the oesophagus. After this operation, you're 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're able to eat and drink again.

You may also have a fine tube inserted up your nose and down into your stomach or small intestine. This is called a nasogastric (NG) tube and allows any fluids to be removed. This will stop you feeling sick and help the area of the operation heal.

You may feel afraid to swallow for a short period of time. You may also have a bad taste in your mouth. Mouthwashes can help relieve this.

At first, you'll probably only be given sips of liquid until the join in your oesophagus has healed enough. It will be a few days before you're able to drink normally. Gradually, you'll also be able to eat normally again.

Some surgeons will also place a small feeding tube directly into the small intestine during the surgery. This is to feed you while you recover. It is usually removed after you have started to swallow normally.

Endoscopic treatments

These involve using an endoscope to deliver treatments that destroy abnormal cells in the oesophagus lining. An endoscope is a thin, flexible tube.

Radiofrequency ablation (RFA)

RFA uses heat to destroy abnormal cells. A probe called an electrode is used to give an electrical current (radiofrequency) to the abnormal area. The electrical current heats the abnormal cells to a high temperature, which destroys (ablates) them. This treatment is usually done under a local anaesthetic with sedation.

The main side effects can include mild pain or discomfort, feeling generally unwell and a high temperature. RFA is most often given to people who have high-grade dysplasia. Your doctor can tell you more about it.

Other endoscopic techniques

Other ways of treating Barrett's oesophagus include argon plasma coagulation, photodynamic therapy (PDT), multipolar electrocoagulation and cryotherapy.

Your specialist can tell you more about these treatments and whether any are appropriate for you.


Your feelings

It's often difficult to find information and support when you’re diagnosed with a condition such as Barrett's oesophagus. You may have concerns about which is the right treatment for you. It's important to discuss these concerns with your doctors and nurses. You may also find the organisations listed below helpful.

You may have many different emotions, including anger and resentment, guilt, anxiety and fear. These are all normal reactions. They are part of the process many people go through when coming to terms with their condition.

Everyone has their own way of coping with difficult situations. Some people find it helpful to talk to family or friends. Others prefer to seek help from people outside of their situation, such as a counsellor. Some people prefer to keep their feelings to themselves. There is no right or wrong way to cope, but help is available if you need it. Our cancer support specialists can give you support and information about counselling in your area.


Useful organisations

Barrett's Oesophagus Campaign

Barrett's Oesophagus Campaign promotes research into Barrett’s oesophagus. Its website has useful information, including leaflets you can download.

CORE

CORE provides information on any aspect of digestive problems.

Oesophageal Patients Association

Oesophageal Patients Association gives support and information to people affected by oesophageal cancer.

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