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Barrett's oesophagus

Barrett's oesophagus is when the cells that line the lower part of your oesophagus get damaged by acid and bile travelling upwards from your stomach. Barrett's oesophagus is becoming more common in the UK. It’s estimated to affect around two in every 100 people.

 

Image showing the digestive system

Details

  • About About Barrett's oesophagus

    Your oesophagus is part of your digestive system – it’s the tube that goes from your mouth to your stomach. The medical term for acid and bile travelling back up from your stomach is gastro-oesophageal reflux.

    You can get Barrett's oesophagus if you have gastro-oesophageal reflux for a long time – often over five years. Acid and bile that travels up from your stomach may eventually cause the skin-like cells in the lower part of your oesophagus to change. They become more like the cells that line your stomach and small intestine.

  • Symptoms Symptoms of Barrett's oesophagus

    Barrett’s oesophagus doesn't cause any symptoms of its own. You may have symptoms of gastro-oesophageal reflux though, which can trigger Barrett’s oesophagus. These may include:

    • heartburn
    • indigestion
    • food coming back up the wrong way
    • difficulty swallowing

    If you have heartburn or indigestion, a pharmacist may be able to advise you on treatments that can help. But if your symptoms continue, see your GP for advice.

  • Diagnosis Diagnosis of Barrett's oesophagus

    Your GP will ask about your symptoms and may examine you. They may also ask you about your medical history.

    Your GP may arrange for you to have a test called an endoscopy (or a gastroscopy). This allows a specialist doctor called a gastroenterologist or specialist nurse to look inside your oesophagus and stomach using a narrow, flexible, tube-like telescopic camera. It can help to identify whether your symptoms are related to Barrett’s oesophagus or another condition. Sometimes your doctor or nurse may take a small sample of tissue (a biopsy) from the lining of your oesophagus during the test. They’ll send this to a laboratory to confirm your diagnosis and to check if the cells are abnormal.

    Barrett's oesophagus is sometimes picked up if you have an endoscopy to investigate another problem, such as tummy pain.

    If you're diagnosed with Barrett's oesophagus, your GP or gastroenterologist may want to monitor your condition. They’ll arrange for you to have an endoscopy with biopsies at regular intervals. This will help to detect any abnormal changes that may develop in the cells in your oesophagus. You may need to have these check-ups at intervals from anywhere between a few months to five years, depending on how severe your condition is.

    It’s not always necessary to monitor Barrett's oesophagus in this way. Your doctor will tell you if you need to be monitored and will be able to explain the reasons why.

  • Self-help Self-help for Barrett's oesophagus

    Your doctor may advise you to make some changes to your lifestyle to help reduce gastro-oesophageal reflux, which may control the condition. For example, they might suggest you:

    • lose weight (if you're overweight)
    • stop smoking
    • drink less alcohol and coffee
    • don't eat foods that aggravate your symptoms, such as fatty foods – keep a diary so you know which ones do
    • eat smaller meals at regular intervals, rather than a large amount in one go
    • use an extra pillow or two if you get reflux symptoms at night 
  • Treatment Treatment of Barrett's oesophagus

    Treatments for Barrett's oesophagus are targeted at preventing further gastro-oesophageal reflux and, if necessary, removing any damaged areas of tissue from your oesophagus.

    Medicines

    Your doctor may prescribe you medicines to reduce the amount of stomach acid you produce. This should in turn reduce gastro-oesophageal reflux. They’ll usually prescribe you medicines called proton pump inhibitors. Examples of these include omeprazole, rabeprazole and lansoprazole. You may need to take these medicines long-term to control your symptoms.

    Your doctor may prescribe another type of medicine called an H2 receptor blocker, for example ranitidine, to reduce the amount of stomach acid you produce.

    If medicines don't work, your GP may refer you to a gastroenterologist (a doctor who specialises in the digestive system) to talk about more options.

    Non-surgical treatment

    If tests show that your cells are continuing to change, there’s a risk that they may develop into cancer cells. See Complications of Barrett’s oesophagus and FAQ: After how long does it turn into cancer? to find out more. If this happens, you may need further treatment.

    Specialist centres offer treatments to remove the layer of damaged cells using an endoscope. Healthy cells usually regrow over the area after this.

    Endoscopic treatments include the following.

    • Radiofrequency ablation uses heat to destroy the abnormal cells. Your doctor will use a probe to apply an electrical current to the abnormal cells in your oesophagus. This will heat them up until they are destroyed. This is the most common way to treat precancerous cells. See our section on Barrett's oesophagus and cancer to find out more.
    • Endoscopic mucosal resection is a treatment to lift the affected tissue away from the wall of your oesophagus and cut it out. Your doctor may use ablation therapy before or after this, to help get rid of the damaged cells. This technique is often used to remove very early cancer of the oesophagus.
    • Photodynamic therapy uses a laser to deliver light energy to destroy the abnormal cells in your oesophagus. You’ll first be given a special medicine, called a photosensitising agent, which makes the abnormal cells sensitive to light.

    Your doctor or surgeon will tell you if any of these treatments are suitable for you. They might not be available in all hospitals, and you may need to be referred to a hospital that specialises in them.

    Surgery

    If your gastroenterologist thinks you may benefit from surgery, they’ll refer you to a surgeon to discuss your options. There are two types of surgery for Barrett's oesophagus.

    Fundoplication

    This is an operation to strengthen the valve at the bottom of your oesophagus, which prevents further gastro-oesophageal reflux. In the operation, your surgeon will wrap the top part of your stomach around the bottom end of your oesophagus. For more information about what’s involved, see Related information.

    Your doctor may recommend this surgery if your symptoms are really bothering you but you don’t want to take medicines for the rest of your life. It may also be an option if you have side-effects from acid-reducing medicines.

    Oesophagectomy

    This is an operation to remove the affected area of your oesophagus. Your doctor may advise you to have this operation if you’ve developed an early cancer as a complication of Barrett’s oesophagus. In this operation, your surgeon will remove the affected section of your oesophagus and then join your stomach to the remaining part.

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  • Causes Causes of Barrett's oesophagus

    Barrett's oesophagus is caused by long-term reflux of acid and bile. This is when stomach acid and digestive juices travel upwards from your stomach into the lower part of your oesophagus.

    Usually, stomach acid is kept in your stomach by a muscular valve that stops it from reaching your oesophagus. But if you have Barrett's oesophagus, your valve may have become weak or moved out of place, which allows acid to leak upwards. Your stomach is protected from digestive juices by a lining of acid-resistant cells. But the lining of your oesophagus is different, and it can become inflamed and irritated as it tries to protect itself from damage by reflux.

    You're more likely to get gastro-oesophageal reflux if you:

    • smoke
    • drink alcohol
    • eat big meals
    • are overweight
    • have a hiatus hernia
    • are white
    • are male
    • are over 50
    Only about one in 20 people who have reflux go on to develop Barrett's oesophagus. You're more likely to develop it if you’ve had severe reflux symptoms for many years.
  • Complications Complications of Barrett's oesophagus

    For some people, the constant exposure to acid and bile from gastro-oesophageal reflux over a long period of time causes complications, including:

    • ulcers, which can be painful when you swallow food, and if severe, cause blood in your vomit or faeces (which will look black and tar-like)
    • scarring of your oesophagus (stricture), which may narrow your oesophagus and make it difficult to swallow
    • cancer of the oesophagus (see next section) 
  • Barrett's oesophagus and cancer Barrett's oesophagus and cancer

    Most people with Barrett's oesophagus don't have any serious problems from the condition. But in some people, the changes in the cells that line the oesophagus develop into cancer. This happens to around one or two people in every 20 with Barrett's oesophagus. And it usually takes many years or decades for cancer to develop.

    During this time, the cells go through a series of pre-cancerous changes called metaplasia and dysplasia. Dysplasia can be labelled low-grade or high-grade, depending on the how much the cells have changed. Cells that have high-grade dysplasia have changed the most, and have the highest risk of turning cancerous.

    Not everyone who gets high-grade dysplasia will develop oesophageal cancer. But if you do have these cells, your doctor will monitor you so they can detect and treat any changes in your cells early.

  • FAQ: Barrett's and oesophageal cancer Does everyone with oesophageal cancer get Barrett's first?

    No, not everyone with oesophageal cancer will have had Barrett's oesophagus first.

    There are two types of oesophageal cancer – adenocarcinoma and squamous cell carcinoma. Adenocarcinoma usually develops in people who have Barrett's oesophagus, but squamous cell carcinoma isn't linked to the condition. So you can develop this type of cancer without having had symptoms of Barrett’s first.

    Even if you do have Barrett’s oesophagus, you may not realise you have it. This may either be because you haven’t had any symptoms of reflux, or you’ve only had mild symptoms and haven’t needed an endoscopy. If you have symptoms such as heartburn or indigestion, or if you have reflux, or pain or difficulty swallowing, it’s important to contact your GP.

  • FAQ: Is there a cure? Can radiofrequency ablation cure Barrett's?

    Yes, radiofrequency ablation therapy can cure Barrett's oesophagus.

    More information

    Radiofrequency ablation can completely cure Barrett's oesophagus. After treatment you’ll probably still need to take acid suppressing medicines but your risk of oesophageal cancer will be significantly lower. Doctors usually recommend radiofrequency ablation as an alternative to surgery if you have low or high-grade dysplasia.

    At the moment, there isn’t enough evidence to recommend that everybody with Barrett’s oesophagus have radiotherapy ablation. This is because the vast majority of people won’t develop dysplasia or cancer from having the condition.

    There are also some disadvantages of radiofrequency ablation. You may find you get some chest pain and there’s a risk you may develop areas of narrowing (strictures) in your oesophagus. These can be treated by further endoscopic treatment. Other potential side-effects of the treatment include bleeding and punctures in your oesophagus.

    Ask your doctor for more information about the potential benefits and risks of radiofrequency ablation and if it's an option for you.

  • FAQ: Time for cancer to develop How long does it take to develop cancer?

    Most people with Barrett's oesophagus don't go on to develop cancer at all. In those who do, it usually takes many years for the cancer to develop.

    More information

    The progression of Barrett's oesophagus to cancer is usually a very gradual process that happens over a number of years. Cells in the damaged area of the oesophagus go through a number of changes before they become cancerous. See section on Barrett's oesophagus and cancer to learn more about this.

    It can take up to 20 years for cells with these changes (known as ‘dysplasia’) to develop into cancer, although this is different for everyone. In some people, the dysplasia never progresses to cancer. Certain things can increase your risk of progressing to oesophageal cancer. It’s more likely to happen in men, and other risks include:

    • getting older
    • smoking
    • how much of your oesophagus is affected by Barrett's oesophagus – the more that’s affected, the higher your risk

    If you're diagnosed with Barrett's oesophagus and dysplasia, your doctor will suggest you have regular check-ups so they can monitor any changes in your cells. They may refer you to a specialist unit for these. If you have high-grade dysplasia, your doctor may recommend you have an endoscopic treatment, such as radiofrequency ablation, to remove the damaged cells. 

  • Other helpful websites Other helpful websites

    Sources

    • Barrett esophagus. Medscape. emedicine.medscape.com, updated 3 January 2016
    • Barrett's oesophagus. BMJ Best Practice. bestpractice.bmj.com, last updated 14 September 2015
    • Gastroesophageal reflux disease. Medscape. emedicine.medscape.com, updated 3 January 2016
    • Barrett's oesophagus. PatientPlus. patient.info/patientplus, last checked 23 January 2014
    • Upper gastrointestinal surgery. Oxford Handbook of Clinical Surgery (online). Oxford Medicine Online. oxfordmedicine.com, published May 2013
    • Endoscopic radiofrequency ablation for Barrett's oesophagus with low-grade dysplasia or no dysplasia. National Institute for Health and Care Excellence (NICE), 23 July 2014. www.nice.org.uk
    • Upper GI endoscopy: what to expect. International Foundation for Functional Gastrointestinal Disorders. www.iffgd.org, last updated 4 September 2015
    • Fitzgerald RC, Di Pietro M, Ragunath K, et al. British Society of Gastroenterology guidelines on the diagnosis and management of Barrett's oesophagus. Gut 2014; 63(1):7–42. doi: 10.1136/gutjnl-2013-305372
    • Map of Medicine. Barrett’s oesophagus. International View. London: Map of Medicine; 2015 (Issue 1).
    • Joint Formulary Committee. British National Formulary (online) London: BMJ Group and Pharmaceutical Press. www.medicinescomplete.com, accessed 14 April 2016
    • Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management. National Institute for Health and Care Excellence (NICE), 3 September 2014. www.nice.org.uk
    • Endoscopic mucosal resection. Medscape. emedicine.medscape.com, updated 6 August 2015
    • Photodynamic therapy for Barrett's oesophagus. National Institute for Health and Care Excellence (NICE), 23 June 2010. www.nice.org.uk
    • Laparoscopic Nissen fundoplication. Medscape. emedicine.medscape.com, updated 18May 2014
    • Minimally invasive oesophagectomy. National Institute for Health and Care Excellence (NICE), 28 September 2011. www.nice.org.uk
    • Gastroesophageal reflux disease (GERD). The MSD Manuals. www.msdmanuals.com, last full review/revision date May 2014
    • Complications. Barrett's Oesophagus Campaign. www.barrettscampaign.org.uk, accessed 18 April 2016
    • Chronic management – Barrett's oesophagus. British Society of Gastroenterology. www.bsg.org.uk, accessed 14 April 2016
    • Oesophageal cancer. BMJ Best Practice. bestpractice.bmj.com, last updated 21 March 2016
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    Reviewed by Rachael Mayfield-Blake, Freelance Health Editor, Bupa Health Content Team, June 2016

    Peer reviewed by Dr Ian Penman, Consultant Gastroenterologist, Spire Edinburgh Hospitals

    Next review due: June 2019

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