Barrett’s oesophagus

Introduction

Barrett’s oesophagus is a premalignant condition in which the normal stratified squamous epithelium of the distal oesophagus is replaced by metaplastic columnar epithelium. This occurs in response to chronic gastro-oesophageal reflux disease (GORD) and increases the risk of oesophageal adenocarcinoma.

Peak Incidence

• Most commonly affects individuals aged 50 to 70 years.
• More prevalent in males and those with a long-standing history of GORD.

Pathophysiology

• Chronic acid exposure from gastro-oesophageal reflux leads to injury of the squamous epithelium.
• In response, the epithelium undergoes metaplasia, transforming into non-ciliated columnar epithelium with intestinal features, including goblet cells (intestinal metaplasia).
• This adaptive change protects against acid but carries a risk of progression to dysplasia and eventually adenocarcinoma.
• Risk factors include male sex, central obesity, smoking, Caucasian ethnicity, and a long duration of reflux symptoms.

Symptoms

Barrett’s oesophagus itself is usually asymptomatic. Symptoms are typically due to underlying GORD:

• Heartburn (burning retrosternal chest pain).
• Regurgitation of food or acid.
• Dysphagia (difficulty swallowing, especially solids).
• Chronic cough or hoarseness (due to laryngeal irritation).
• Nausea and epigastric discomfort.

Signs

• No pathognomonic signs, but some patients may show features of chronic reflux:
  • Dental enamel erosion.
  • Laryngeal irritation (e.g. erythema, oedema on laryngoscopy).

Diagnosis

Gold standard: Upper gastrointestinal (GI) endoscopy with biopsy.

• Endoscopic findings: salmon-coloured mucosa extending ≥1 cm above the gastro-oesophageal junction (GOJ).
• Histological confirmation: biopsy must demonstrate intestinal metaplasia, specifically goblet cells within columnar epithelium.

Additional investigations:

• Barium swallow: used for evaluating dysphagia and strictures.
• 24-hour pH monitoring: confirms pathological acid reflux, especially in atypical or persistent symptoms.
• Oesophageal manometry: assesses for motility disorders before anti-reflux surgery.

Complications

• Reflux oesophagitis: mucosal erosions and ulceration.
• Oesophageal strictures: fibrosis causes progressive dysphagia.
• Iron-deficiency anaemia: due to chronic blood loss from mucosal erosions.
• Dysplasia: metaplasia may progress to low-grade or high-grade dysplasia.
• Oesophageal adenocarcinoma:
  • Barrett’s confers a 50–100-fold increased risk of developing adenocarcinoma compared to the general population.

Management

1. Lifestyle Modifications:

• Weight loss.
• Smoking cessation.
• Avoid alcohol, caffeine, spicy foods, and large meals.
• Avoid late-night eating.
• Elevate head of bed to reduce nocturnal reflux.

2. Pharmacological Management:

• High-dose proton pump inhibitors (PPIs) (e.g. omeprazole, esomeprazole) to reduce acid exposure and promote mucosal healing.

3. Endoscopic Surveillance:

• Non-dysplastic Barrett’s:
  • <3 cm segment: surveillance endoscopy every 5 years.
  • ≥3 cm segment: surveillance endoscopy every 3 years.

4. Management of Dysplasia:

• Low-grade dysplasia:
  • First-line: Radiofrequency ablation (RFA) ± Endoscopic mucosal resection (EMR).
  • In selected cases: continued surveillance may be offered after MDT discussion.
• High-grade dysplasia:
  • First-line: RFA ± EMR or Endoscopic Submucosal Dissection (ESD).
  • Second-line: Oesophagectomy if endoscopic treatment is not feasible or malignancy is suspected.