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 it can develop into cancer in a small number of people.

The main cause of Barrett's oesophagus is acid reflux. It happens when acid or bile in the stomach juices splashes back into the oesophagus. Acid reflux can inflame the oesophagus. This may lead to a condition called gastro-oesophageal reflux disease (GORD). Around 1 in 10 people (10%) with acid reflux will develop Barrett's oesophagus.

The most common symptom of Barrett’s oesophagus is ongoing heartburn and indigestion. Sometimes the reflux does not cause symptoms. This is called ‘silent reflux’.

Barrett’s oesophagus is diagnosed by examining the oesophagus using an endoscope. A sample of cells (a biopsy) may be taken.

Barrett’s oesophagus can be managed in different ways. The aim of treatment is to reduce reflux, control symptoms and prevent cancer. Making lifestyle changes and having medicines can reduce the amount of acid in your stomach. Surgery to strengthen the valve at the lower end of the oesophagus can also be used. If the cells are becoming very abnormal, they are sometimes removed.

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 occur at any age. It can affect both men and women, but it is more common in men.

The cell changes in Barrett’s oesophagus can sometimes develop into something called dysplasia. 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 a cancer. However, over time the cells can become more abnormal. Sometimes this develops into a cancer called adenocarcinoma of the oesophagus. Cancer develops when the normal workings of a cell go wrong and the cell becomes abnormal. The abnormal cell keeps dividing, making more and more abnormal cells. These eventually form a lump (tumour).

Less than 2 out of every 200 people (less than 1%) in the UK have Barrett's oesophagus. And very few people with this condition develop cancer. About 3 in every 100 people (3%) who have Barrett's oesophagus will develop oesophageal cancer during their lifetime.

The oesophagus and surrounding organs
The oesophagus and surrounding organs

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Causes of Barrett's oesophagus

The main cause of Barrett’s oesophagus is gastro-oesophageal reflux.

Reflux happens when the valve at the lower end of the oesophagus is weak and lets stomach juices splash up into the oesophagus. Reflux of acid and bile is very common. Many people have symptoms at some point in their lives.

Your risk of developing reflux is greater if you:

  • are overweight
  • smoke
  • drink too much alcohol
  • eat spicy, acidic or fatty foods
  • have a hiatus hernia.

A hiatus hernia is when part of the stomach is displaced and pokes up through the diaphragm. The diaphragm is the sheet of muscle that divides the tummy area from the chest. It helps to keep acid and bile in the stomach.

The stomach produces acid to help digest food. The stomach is lined by tissue that is resistant to acid, but 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. The change of the normal lining of the oesophagus into Barrett’s oesophagus is thought to be caused by exposure to acid and perhaps bile during times of reflux.

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 have had severe reflux for many years. It is also more common in men and people over 50.


Signs and symptoms of Barrett’s oesophagus

Barrett’s oesophagus has no symptoms. However, most people will have symptoms of gastro-oesophageal reflux disease (GORD).

The most common symptoms of GORD are heartburn and indigestion.

Other symptoms include:

  • an unpleasant, sour taste in the mouth caused when reflux fluids are brought back up into the throat or mouth (regurgitation)
  • feeling sick (nausea)
  • being sick (vomiting)
  • chest pain.

If you have any of these problems for more than two weeks you should see your GP.

Symptoms that might be a sign of a more serious problem include:

  • difficulty swallowing food (dysphagia)
  • vomiting blood
  • pain when swallowing food.

These symptoms need urgent investigation and should be reported to your doctor straight away.


Diagnosing Barrett's oesophagus

Barrett’s oesophagus is usually diagnosed when people have an endoscopy because they have symptoms of GORD, or for other reasons.

If you have symptoms of GORD, your GP will refer you to the hospital for an endoscopy. This is a test to examine the lining of your oesophagus. Endoscopies can also be used to give treatment.

Endoscopy

A doctor or specialist nurse will do the endoscopy. They will examine the lining of the oesophagus using a thin, flexible tube called an endoscope. There is a tiny light and camera on the end of the tube. This helps to see any abnormal areas. Small samples of cells (biopsies) can be taken and examined under a microscope. The biopsy is not painful.

You will usually have an endoscopy in the hospital outpatient department. Occasionally you will need to stay in hospital overnight. You will be asked not to eat or drink for at least four hours before the procedure. You will also be given instructions about any medicines you are taking.

To have the endoscopy, you will be asked to lie on your side on a couch. A local anaesthetic may be sprayed on to the back of your throat. Or you may be given a sedative to make you feel sleepy and reduce any discomfort. The sedative is usually injected into a vein in your hand or arm. Sometimes both an injection and the spray are used. The doctor or nurse then passes the endoscope down your oesophagus.

An endoscopy can be uncomfortable but it isn't painful. It usually takes about 10 to 15 minutes. After a few hours, the effect of the sedative will wear off and you will be able to go home.

If you 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 an hour. You should not 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 had a sedative, you should not drive for several hours after the test. You will need to arrange for someone to travel home with you.

Some people have a sore throat after the procedure. This is normal and usually goes 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.


Managing Barrett's oesophagus

The management of Barrett’s oesophagus aims to reduce acid reflux and control symptoms. Sometimes an operation is used to strengthen the valve at the bottom of the oesophagus or to remove the affected area.

The best way to manage Barrett’s oesophagus will depend on your situation. Some people will have their condition monitored regularly. Others will be advised to have treatment. Your doctor or specialist nurse will discuss the options with you.

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. Your doctor will talk to you about the benefits and disadvantages of surveillance.

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.

The aim of surveillance is to find early changes (dysplasia) that may develop into cancer. Treatment can then be given to prevent cancer developing. Sometimes surveillance finds cancer in the very early stages, when treatment can be given to cure it.

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

Reducing acid reflux

Lifestyle changes

Sometimes it is possible to reduce acid reflux by making some lifestyle changes. If you are overweight, the most important thing to do is lose some weight. Even a small amount of weight loss is helpful. 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 two to three hours before bedtime and avoid late night snacks if possible. This is because eating encourages the stomach to produce more acid. This 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 stomach 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 GORD. 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 safe to take over a long time.

Fundoplication

This is a small operation to strengthen the valve at the bottom of the oesophagus or repair a hiatus hernia. During surgery, 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 tummy (abdomen), rather than one large opening. Sometimes it does involve a large incision in the abdomen (a laparotomy).

Removing the affected area

If a biopsy shows that there are continuing changes in the cells which may progress to cancer, your specialist may suggest treatment to remove the affected area. This can be done in different ways. These include endoscopic mucosal resection, radiofrequency ablation (RFA) and surgical resection.

Endoscopic mucosal resection (EMR)

The aim of EMR is to remove the affected area of the oesophagus lining, without damaging the rest of the oesophagus. The affected area is removed using a thin wire called a snare. The snare is put through an endoscope.

EMR can be done as a day case under sedation, but you may need to stay in hospital overnight.

EMR may be followed by radiofrequency ablation or surgical resection (see below).

Radiofrequency ablation (RFA)

RFA uses heat to destroy abnormal cells. Using an endoscope, 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 sedation. RFA is done at specialist centres, so you may have to travel for treatment.

The main side effects can include mild pain or discomfort. Some people feel generally unwell and have a high temperature for a few days.

Your doctor can tell you more about possible side effects.

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 are likely to spend a short time in the intensive care unit. You will have a drip put into a vein in your hand or arm until you can 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.

To start with you may feel afraid to swallow. You may also have a bad taste in your mouth. Mouthwashes can help with this.

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

Some surgeons place a small feeding tube directly into the small intestine during the operation. This is to feed you while you recover. It is usually removed after you have started to swallow normally. Your doctor will discuss this with you if they plan to give you a feeding tube.

Other endoscopic techniques

Other ways of treating Barrett's oesophagus include:

• argon plasma coagulation

photodynamic therapy (PDT)

• multipolar electrocoagulation

• cryotherapy.

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

Research

Research is ongoing into new ways to diagnose and treat Barrett’s oesophagus. You may be asked to take part in a trial looking at possible drug treatment and how best to undertake surveillance. Your doctor or specialist nurse will discuss this with you.


Your feelings

It is often difficult to find information and support when you are diagnosed with a condition such as Barrett's oesophagus. You may have concerns about which is the right treatment for you. It is 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.

Heartburn Cancer UK

HCUK provides information about Barrett’s oesophagus and oesophageal cancer.

Action Against Heartburn

Action against Heartburn provides information about heartburn and Barrett’s oesophagus.

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