Barrett’s esophagus (BE), a term that just a few decades ago was relatively unknown or unheard of. Today, if you are one of the 20% in the United States suffering from Gastroesophageal Reflux Disease (GERD) or heartburn, then you may have heard of the term Barrett’s esophagus. What is it? Why is it important to understand it? How can you detect it and treat it?
Before understanding BE, it helps to have a basic understanding of the human anatomy as it pertains to the esophagus, stomach and most importantly, the junction of the two.
The esophagus is a muscular tube connecting the throat to the stomach from which food and liquid passes through a connecting point called the lower esophageal sphincter (LES) to the stomach. The thorax or chest is separated from the abdominal cavity by muscle called the diaphragm. The LES sits at an opening in the diaphragm. When this mechanical system from the throat, down the esophagus and through the LES functions properly, it allows contents to flow through to the stomach, but stops stomach contents (i.e. food, liquid, acid and bile) from flowing up into the esophagus.
It is important to note that this process is mechanical, not chemical or biochemical. What does this mean? The human stomach contains acid, which helps us digest food and protects us from bacteria and other organisms. Without stomach acids, food and liquids do not digest properly, gastro-intestinal infections may occur, as well as other ailments.
So, what causes GERD, heartburn or acid reflux? Although there could be several causes for the burning, painful feeling in the lower chest that is associated with GERD, hence the name “heartburn”, in the majority of the cases, GERD is caused by a hiatal hernia. There are 2 major types of hiatal hernias:
- A sliding hiatal hernia – This occurs when the esophagus and stomach slide up the opening of the diaphragm from which the esophagus passes to connect to the stomach. One of the major causes of this is being overweight. Over time, the pressure of a large midsection pushing up against the diaphragm opening can cause it to weaken, which in turn can cause the esophagus and stomach to slide up through the opening.
- A paraesophageal hernia – Occurs when there is a tear in the muscle tissue known as the diaphragm. This can cause the stomach to bulge through the diaphragm next the esophagus.
Some of the major causes of these hernias are:
- Overweight or obesity – the excess pressure caused by the abdomen on the diaphragm can push up the esophagus and stomach causing a sliding hiatal hernia or can tear the diaphragm causing a paraesophageal hernia.
- Age – as humans’ age, their muscles and bones become more frail and can lead to injury. This is also the case of the diaphragm, with age, it can become weaker and tear causing both types of hernias.
- Stress due to lifting – both types of hernias can be caused through lifting heavy objects, weight training, pressure due to athletic training and more. In fact, hiatal hernias are not uncommon in athletes.
- Smoking, alcohol, mint, coffee among other items can also weaken the LES causing stomach contents to go up the esophagus.
- Pregnancy – in particular, multiple pregnancies due to the repeated pressure to the abdomen and diaphragm, this may cause a sliding hiatal hernia or in more severe cases a paraesophageal hernia. In most cases, following birth the sliding hiatal hernia will correct itself.
This mechanical failure causes stomach contents to go into the esophagus. This content may include:
- Acid
- Food
- Bile
It is the acid, which causes the painful, burning sensation, sometimes mimicking the pain of a heart attack. This is because, human stomachs are designed to contain acid, and the esophagus is not.
Barrett’s esophagus
Barrett’s esophagus refers to abnormal change in the cells of the lower esophagus, which can lead to esophageal cancer. Traditionally, this was thought to occur due to the acid, however, more recent studies indicate that bile is probably the culprit, which would explain how GERD patients using medication to stop the production of acid can still develop BE.
How does Barrett’s occur? The human being is a very adoptive species, which is why we have survived for tens of thousands of years. When stomach content repeatedly flows back up into the esophagus, the cells in the esophagus start to change in order to protect them. They begin a process in which the esophageal cells start to become more similar to stomach cells. These damaged cells have although relatively rare; have a higher likelihood of become adenocarcinoma cells (cancer). Unfortunately, there are very few symptoms of esophageal cancer until the disease has progressed to stage 3 or 4, making it one of the most deadly cancers to contract.
Detecting Barrett’s esophagus
Because of the link between Barrett’s esophagus and esophageal cancer, it is important for people that are susceptible to BE to detect it at an early stage and treat it. As in many diseases, the earlier the detection, the easier it is to treat and the higher probability of curing the patient.
So how do you detect Barrett’s esophagus?
If you have any symptoms of GERD, you should see a specialist to determine the root cause. Symptoms may include:
- Frequent and / or persistent heartburn
- Chest pain (If this is accompanied by shortness of breath, arm or jaw pain, contact 911 immediately, these might be signs of a heart attack.)
- Dysphagia (i.e. difficulty swallowing)
- Globus sensation (i.e. feeling like there is food at the back of the throat)
- Hoarseness or soar throat
- Persistent bad breath
- Dental erosion / cavities
To determine the cause of the reflux, the specialist can do a number of tests including:
- Upper GI Series or X-ray of Upper Digestive System
- Endoscopy
- Bravo Esophageal pH Monitoring
- Esophageal Manometry
For more information on these tests, click here
In order to detect Barrett’s esophagus, there are more specific and accurate tests that can be done beyond a traditional endoscopy, which sends a small camera into the esophagus that a physician can see noticeable changes along the esophageal wall. However, early onset BE might not be detectable with the camera, nor might the early stages of cancer. In order to be more accurate, the physician can do the following:
- A biopsy – however, the traditional means of doing a biopsy is to take 4 small sections of the esophagus wall (i.e. front, back left & right). This leaves significant room for error.
- Cellvizio – a new technology that generates optical biopsies, providing microscopic images of tissue. In layman terms, this powerful camera allows a physician to identify Barrett’s esophagus and cancer cells in real time through a camera. For more information, click here.
- WATS3D – This cutting edge technology allows the physician to take a comprehensive sample of the esophagus wall, minimizing the chance of missing BE or cancerous cells. Unlike a traditional biopsy that typically takes 4 small samples, leaving significant room for error. More information on WATS3D can be found by clicking here.
If Barrett’s esophagus is identified, what is the treatment? Although the chances of Barrett’s becoming cancer is relatively small, it is prudent to remove the BE cells at this stage rather than waiting until they develop into cancer. The process is relatively simple and is a non-surgical, outpatient procedure called Radiofrequency Ablation (RFA). This procedure delivers radiofrequency or radio waves via a catheter to the diseased area of the esophagus, which minimizes destruction of healthy tissue. Within a few weeks, normal, healthy cells replaced the destroyed ones. For more information on RFA, please click here.
Summary
- A mechanical issue, typically a sliding hiatal hernia or paraesophageal hernia, often causes GERD, acid reflux or heartburn. Due to this, medications such as proton pump inhibitors (PPI), H2 antagonist or H2 blockers, although they can provide temporary pain relief, do not treat the root cause of the problem.
- As such, identifying the root cause is critical in taking the appropriate actions to treat the disease as opposed to only the symptoms.
- Stomach contents, in particular bile, being regurgitated into the esophagus can damage and change the esophageal tissue into what is known as Barrett’s esophagus.
- Barrett’s esophagus is a precursor to adenocarcinoma, a lethal form of cancer.
- Early identification of BE will allow for the non-surgical treatment of the pre-cancerous cells through radiofrequency ablation (RFA), destroying the diseased cells that are typically replaced by healthy tissue.
This article reviews, in limited form, the diagnostic practices and treatment procedures of the Heartburn Center of California and Dr. Wilson Tsai for Barrett’s esophagus and is meant for informative purposes only. Patients experiencing GERD, reflux or heartburn symptoms or any other symptoms should seek help from their healthcare professional.
For more information on GERD and related symptoms, please visit www.heartburncenterofcalifornia.com or call us at+1 (925) 809-4373 to schedule an appointment with Dr. Tsai.