Barrett’s Esophagus (BE) is a condition where the tissue lining the lower part of the swallowing tube, or esophagus, undergoes an abnormal change. While BE itself is not cancer, it is the only known precursor to esophageal adenocarcinoma (EAC), a highly aggressive form of cancer. The seriousness of a BE diagnosis lies in its malignant potential and the necessity for ongoing medical attention to prevent progression. Although the risk of advancing to cancer remains low for most individuals, the potential lethality of EAC makes BE an important focus for screening and management.
Understanding the Transformation of Esophageal Tissue
The diagnosis of Barrett’s Esophagus is made when the normal lining of the lower esophagus is replaced by a different type of cell. The healthy esophagus is lined with flat, layered cells known as stratified squamous epithelium. This tissue is designed to withstand the physical passage of food but is sensitive to acid.
When stomach contents repeatedly reflux into the esophagus, the tissue becomes damaged, a condition known as chronic gastroesophageal reflux disease (GERD). The squamous cells are replaced by specialized columnar cells, which are more resistant to the digestive fluids. This cellular change is called specialized intestinal metaplasia because the cells begin to look like the lining of the small intestine.
This metaplasia marks the presence of Barrett’s Esophagus. The cellular change is often asymptomatic, so detection usually occurs during an endoscopy performed due to longstanding GERD symptoms. The diagnosis is confirmed only after a biopsy of the affected area is examined under a microscope to identify the specialized intestinal cells.
Assessing the Risk of Progression
The primary concern with Barrett’s Esophagus is its potential to progress through a series of cellular changes toward cancer. These changes move through stages of increasing abnormality known as dysplasia. Dysplasia describes cells that look and grow abnormally but have not yet acquired the ability to invade surrounding tissue.
The severity of the risk is categorized by the degree of dysplasia observed in the biopsy samples. Non-dysplastic BE carries the lowest risk, with the annual rate of progression to cancer estimated to be less than one percent. If the cells show a mild degree of abnormality, the condition is classified as low-grade dysplasia (LGD), which indicates an increased risk.
High-grade dysplasia (HGD) involves significant cellular abnormality and is considered the last stage before invasive cancer. Patients with HGD have an elevated annual risk of progression to esophageal adenocarcinoma, with estimates suggesting a risk of at least 7–13% per year without intervention. The length of the affected segment and the patient’s age are also factors that influence the overall risk of progression.
Surveillance and Treatment Options
Given the risk of progression, the management of Barrett’s Esophagus focuses on controlling the underlying acid reflux and closely monitoring the esophageal tissue. Medical management involves using acid-suppressing medications, such as proton pump inhibitors (PPIs), to reduce chemical damage to the lining.
Regular endoscopic surveillance is required, which involves performing an upper endoscopy to check for early signs of dysplasia. The frequency of these check-ups depends on the degree of cellular change. For patients with non-dysplastic BE, surveillance is generally recommended every three to five years.
If dysplasia is detected, the surveillance interval is shortened, and interventional treatment becomes a primary consideration. For patients diagnosed with low-grade dysplasia, guidelines recommend endoscopic therapy or surveillance every 12 months. High-grade dysplasia warrants interventional treatment to prevent progression to cancer.
Interventional treatments, collectively called endoscopic eradication therapy, are designed to destroy or remove the abnormal tissue. These procedures include Radiofrequency Ablation (RFA), which uses heat energy to burn away the tissue, and Endoscopic Mucosal Resection (EMR), which removes visible abnormal lesions or early-stage cancer. Following successful eradication therapy, patients still require structured surveillance to monitor for any recurrence.