What is Barretts Esophagus?

Author: More Than Just Medicine

Hello I'm Simon Smale I'm a gastroenterologist in York and welcome to More Than Just Medicine, this evening I'm going to talk a bit about Barrett's esophagus first to define it Barrett's esophagus is an esophagus where it's clear that the lining has changed from being what called squamous mucosa, which is what the skin is to colonic mucosa which is similar to the lining of the intestine, such changes are visible endoscopically and instead of getting a nice clear line at the lower end of the gullet as it transitions into the stomach one finds that there is gastric mucosa either in patches or as a continuous lining within the gullet rather than being confined to the stomach, that diagnosis is generally confirmed by biopsy which is reviewed by a pathologist, a person who looks at biopsies and the appearance of cells under a microscope usually barretts occurs in people who've had a long history of reflux but that's not always the case or at least symptomatically they're not always symptomatic It reflects a biological mechanism for the oesophagus trying to protect itself from acid exposure because after all the stomach has lots of acid in it, its designed to have acid in it becuse it helps digest your food and kill the bugs that we eat and therefore if we expose the gullet a acid, rather than being corroded as skin is when its exposed to acid it changes the lining to be of a colona nature so more like that that lines the stomach. So in a way there's a biological reason why the mucosa changes in people with long standing reflux. Why is that important, well it's important because barretts esophagus over a lifetime carries a slightly increased risk for those patients in developing esophageal cancer the estimated risk is probably somewhere around the region ten times greater than those patients who don't have barretts over a lifetime in terms of developing esophageal cancer. Now there are a number of features both within the patients who have barretts and within the barretts itself which further increase the risk of cancer again only a small amount for each classes but a small amount nevertheless those include patients who are male have an increased risk patients who smoke, so those are the patient features. Then it terms of barretts segments itself length of the segment clearly has an impact on the risk of cancer as does the development of changes which intestinal metaplasia, essentially when one looks under a microscope all that means is that the colonic mucosa looks a bit more like that which you would normally expect in the intestine as opposed to straight forward colonic mucosa that looks like bricks on one end all lined up together so we look out for those changes and endoscopically what happens is we can't usually see it endoscopically with normal endoscopes but endoscopists usually experienced in barrett's oesophagus surveillance who have an interest in it will take quadratic biopsies so four biopsies every couple of cm along with biopsies of any abnormal looking area of the barretts and they will be examined very carefully by somebody expert in that field now the risk of intestinal metaplasia per year in terms of cancer will be somewhere in the region of one in two hundred to one in four hundred so its still very small but significant if you happen to be the one person that gets it, simalarly the risks of having a long segment of Barrett's esophagus are greater than a short segment, it's estimated that the risk of a segment less than three centimeters is truly less than one in five hunderd for that reason current UK guidance suggests that we don't surveillance, undertake regular endoscopy, people with less than 3 cm segment because the risks of endoscopy are greater than the risk of a esophageal cancer developing. So those are the features of barretts which increase the risk but what do we look for on top of that when we are undertaking regular surveillance we look for a thing called dysplasia and there are grades of dysplasia. There is low grade dysplasia and then there's a high-grade dysplasia, which is more uncommon but more worrisome. Firstly low grade dysplasia, mindful of the things which increase the risk, the overall risk of developing low grade dysplasia over a decade or two is probably somewhere in the region of one in ten or ten percent most people never get dysplasia of any sort now if you take those people who have low grade dysplasia then the risk of them developing high-grade dysplasia which is a much more worrying find, again is probably about one in ten over decades thats an estimation.

High-grade dysplasia is important and if found needs confirmation, sometimes by repeat endoscopy but certainly by review by a number of experts. Then it requires an action plan to treat it very quickly. I hope thats of some help in explaining a little bit more about barrett's esophagus and what it means. Obviously the findings at endoscopy define the intervals for surveillance and if you have dysplasia particularly low grade dysplasia current UK guidance suggests you should have six monthly surveillance whereas if you have no dysplasia the surveillance interval is much longer. Hope thats of some help, thank you for listening.

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