Barrett's Esophagus and Acid Reflux

Q:  Please discuss Barrett's Esophagus. I have recently been diagnosed with this condition and was told it's considered a pre-cancerous condition (but results are benign at this time) and will need yearly upper endoscopy examinations and treatment with a proton-inhibitor (Prilosec) probably for the foreseeable future. Apparently there is no current cure. Is this a newly discovered condition? I don't see much information about it. Is it possible that the medication will lessen chances of the condition worsening or becoming abnormal in the future?

And probably most important, what can I do to help myself? (I was told not to lie down after eating, to avoid coffee, alcohol, all carbonated beverages, citrus products and that weight loss is helpful.) I've never been a coffee drinker and rarely have alcohol and am not extremely over weight, so how did I get this problem? A general discussion of the condition and what research is being done would be extremely helpful.

A:  First described by Norman Barrett in 1950, Barrett's esophagus is a relatively "new" disease. In the last half-century, only a few people have had diseases named after them.

Barrett's esophagus is a change in the lining of the esophagus as a result of acid reflux from the stomach. The chronic irritation from acid causes the cells lining the inside of the esophagus to change to be more like stomach lining to withstand the acid. That's why you take Prilosec to stop the acid production in your stomach.

Barrett's is seen in about 10% of patients with gastroesophageal reflux disease (GERD) or heartburn who have endoscopy (a direct look with a scope at the esophagus and stomach). GERD is quite a common condition, and probably 20% of people who have it do NOT have classic symptoms of acid reflux, but may experience hoarseness, cough, asthma-like symptoms, or increased mouth saliva.

William Berger, MD, Associate Professor of Medicine (Gastroenterology and Hepatology), told me that adenocarcinoma of the esophagus, presumed to be secondary to Barrett's, is one of the cancers with the fastest rising incidence in the USA. Since up to 5% of people with Barrett's esophagus will go on to develop cancer, the yearly monitoring is crucial.

Barrett's is five times more common in men than women and 20 times more common in whites than African Americans, so middle-aged white men with reflux symptoms especially need to be evaluated.

Why does acid reflux occur? Here are some possible explanations: your lower esophageal sphincter may not be working properly to stop the flow of acid up into the esophagus, the stomach may be secreting extra acid, the opening in your diaphragm may be too large so that the stomach can squeeze back up into your chest (called hiatal hernia).

You have mentioned several things the patient can do to decrease acid reflux. Here are a few more: Eat at least 2 hours before bedtime. Decrease the amount of liquid with your meals to 1/2 cup. Elevate the head of your bed on blocks by six inches.

Treatment with medications or even surgery has not been shown to result in any return of the esophagus back to normal and it may not decrease the chances of progressing to cancer. That's why yearly surveillance is so important. Malignant change of the Barrett's typically occurs without any symptoms.

Dr. Berger also enlightened me about the latest in treatment. He pointed out that the risk of cancer is related to how much of the esophagus is involved -- for example, a longer 10 cm segment is at more risk than 2 cm for developing cancer. There are also degrees of cell change, from low grade to high grade and eventually cancer. In a young healthy person with high grade dysplasia, surgically removing the diseased part of the esophagus is the best approach.

In patients not considered well enough to undergo surgery, various methods to remove the Barrett's have been used. David Staff, MD, formerly an Assistant Professor of Gastroenterology at the Medical College, used photodynamic therapy in patients with precancer or early cancer. This involved utilizing a special laser light to activate a chemical that destroyed the abnormal tissue, allowing normal lining to grow back. Results are encouraging, but further studies are needed. Photodynamic therapy, which I've described in more detail in a previous column, is a cutting edge technique which has also been used for treating brain tumors in children here at Children's Hospital of Wisconsin.

Thank you for asking about Barrett's esophagus. I'm sure there are some readers, especially men with untreated GERD who may be dismissing their heartburn as a nuisance, not realizing they are at risk for Barrett's and even cancer.

"Dear Doctor" is a compilation of patient questions answered by doctors from the Medical College of Wisconsin.