Barrett's oesophagus

Published by Bupa's Health Information Team, May 2011.

This factsheet is for people who have Barrett's oesophagus, or who would like information about it.

Barrett's oesophagus is caused by long-term acid reflux (leaking of acid from the stomach). The acid damages the cells lining the lower part of the oesophagus – the pipe that goes from the mouth to the stomach – and is often associated with symptoms such as heartburn.

About Barrett's oesophagus

In Barrett's oesophagus, acid leaking from your stomach causes the cells in the lower part of your oesophagus to change. They become more like the cells that line your stomach and small intestine. Barrett's oesophagus is becoming more common in the UK and currently affects two in every 100 people.

Most people with Barrett's oesophagus don't have any serious problems, but for a few people, the changes in the cells lining the oesophagus may develop into cancer. However, fewer than one in 100 people with Barrett's oesophagus develop oesophageal cancer every year.

It usually takes many years for cancer to develop. During this time the cells go through a series of pre-cancerous changes called dysplasia. A group of cells with 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.

Most people with Barrett's oesophagus don't get high-grade dysplasia – fewer than one in 10 people develop these cells in their lifetime. Not everyone who gets high-grade dysplasia will develop oesophageal cancer, but your doctor may monitor your condition to make sure any changes in your cells are detected and treated early.

Symptoms of Barrett's oesophagus

You may not get any symptoms of Barrett’s oesophagus. However, common symptoms of the condition can include:

• heartburn
• indigestion

If you regularly get any of these symptoms, see your GP.

Complications of Barrett's oesophagus

For some people the constant exposure to acid over a long period of time causes complications, including ulcers of the oesophagus, scarring of the oesophagus (stricture) and cancer.

Symptoms of an oesophageal ulcer include:

• difficulty or pain when swallowing food
• blood in your vomit or faeces

Scarring may narrow the width of your oesophagus and make swallowing difficult. Your doctor can try to correct this complication with treatment using a narrow, flexible, tube-like telescope called an endoscope. However, it often reoccurs.

Symptoms of oesophageal cancer include weight loss and difficulty swallowing food, which is often painless.

If you have any of these symptoms, see your GP.

Causes of Barrett's oesophagus

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

Usually, your stomach acid is kept in your stomach by a muscular valve that stops it from reaching the oesophagus. However, if you have Barrett's oesophagus, the valve has become weak or has moved out of place allowing the acid to leak out. 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 the acid.

You're more likely to get acid reflux if you:

• smoke
• drink alcohol
• drink coffee
• eat fatty foods and big meals
• are overweight
• have a hiatus hernia (this is when part of your stomach slides up into your chest)

Only about one in 10 people who have acid reflux go on to develop Barrett's oesophagus. You're more likely to develop Barrett's oesophagus if you have had severe reflux symptoms for many years, are Caucasian, male, or over 50.

Diagnosis of Barrett's oesophagus

If you visit your GP with symptoms such as heartburn or indigestion, he or she will examine you and ask about your medical history.

If your GP thinks there may be an underlying cause for your symptoms, he or she may refer you to hospital for a test called a gastroscopy (also called an endoscopy). This test allows a doctor to look inside your oesophagus and stomach, and can help to identify whether your symptoms are caused by Barrett’s oesophagus or another condition. Sometimes the doctor or nurse may also take a small sample of tissue (a biopsy) from the lining of your oesophagus during the test. This will be sent to a laboratory to see if the cells are damaged.

Barrett's oesophagus is sometimes diagnosed if you have been referred for a gastroscopy to investigate other problems, such as abdominal pain or sickness.

If you're diagnosed with Barrett's oesophagus, your doctor may want to continue to monitor your condition, by asking you to have a gastroscopy with biopsies at regular intervals. This monitoring may help your doctor detect any abnormal changes in the cells in your oesophagus as soon as possible. You may need to have these check-ups at intervals from anywhere between a few months to three years, depending on how severe your condition is.

It may not always be necessary to monitor Barrett's oesophagus in this way. Ask your doctor for more information.

Treatment of Barrett's oesophagus

Treatment is aimed at preventing further acid reflux and, if necessary, removing the damaged areas of tissue from your oesophagus.

Self-help

Your GP may advise you to make some lifestyle changes in order to reduce your acid reflux. These include:

• losing weight, if you're overweight
• stopping smoking
• drinking less alcohol and coffee
• not eating foods that aggravate your symptoms
• eating smaller meals at regular intervals, rather than eating a large amount in one go
• raising the head of your bed if you get reflux symptoms at night (you can do this by putting supports under the legs at the head of your bed, so that while sleeping your head is positioned higher than your feet)

Medicines

Your doctor may prescribe medicines to reduce the amount of stomach acid you produce, reducing the acid reflux that you get. These are usually medicines called proton pump inhibitors. Examples include omeprazole, rabeprazole or lansoprazole. You may need to keep taking these medicines for the rest of your life to control your symptoms. Long-term use of proton pump inhibitors is safe.

Occasionally, your doctor may prescribe another type of medicine called a histamine receptor blocker to reduce the amount of stomach acid you produce.

Most people with Barrett’s oesophagus can control their condition with acid-reducing medication. But about one in 10 people need further treatment.

If medicines have not worked, your GP may refer you to a gastroenterologist to discuss other treatment options. A gastroenterologist is a doctor specialising in diseases affecting the digestive system.

Non-surgical treatment

You may need further treatment if tests show that your cells are continuing to change and if your doctor thinks there is a risk that they will become cancerous. Specialist centres now offer non-surgical treatment for people with dysplasia. These treatments remove the layer of damaged cells using an endoscope.

Healthy cells usually regrow in the affected area after endoscopic treatments. Endoscopic treatments include the following.

• Radiofrequency ablation. This uses heat to destroy the abnormal cells. A probe is used to apply an electrical current to the abnormal cells in your oesophagus, which heats them up until they are destroyed. This technique is the most common way of treating high-grade dysplasia.
• Endoscopic mucosal resection. Your doctor will lift the affected tissue away from the wall of the oesophagus and then cut it out. He or she may use ablation therapy before or after this procedure to help get rid of the damaged cells. This technique may be used to remove very early cancer of the oesophagus.
• Photodynamic therapy. This uses a laser to deliver light energy to destroy the abnormal cells in your oesophagus. You will 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. These treatments may not be available in all hospitals, and you may be referred to a hospital that specialises in them.

Surgery

If your gastroenterologist thinks that you may benefit from surgery, he or she will refer you to a surgeon to discuss your options. There are two types of surgery for Barrett's oesophagus that you may be offered.

Fundoplication

This is an operation to strengthen the valve at the bottom of your oesophagus. Your doctor may advise you to have this surgery if you have troublesome reflux symptoms and don’t want to take medication for the rest of your life, or if you have side-effects of acid-reducing drugs. Strengthening the valve prevents further acid reflux. It involves the top part of your stomach being wrapped around the bottom end of your oesophagus.

Oesophagectomy

This is an operation to remove the affected area of your oesophagus. Your doctor may advise you to have this surgery if you have developed an early cancer as a complication of Barrett’s oesophagus. To do this operation your surgeon makes a large cut in your stomach and chest so he or she can take out the affected section of your oesophagus. Your stomach will then be joined to the remaining part of your oesophagus.

Your gastroenterologist will advise you if either of these types of surgery would be helpful or appropriate for you.

As with every procedure, there are some risks associated with the surgical and non-surgical treatments of Barrett’s oesophagus. Ask your doctor or surgeon to explain how these risks apply to you.

For answers to frequently asked questions on this topic, see FAQs.

For sources and links to further information, see Resources.