Barrett’s Oesophagus is the only known risk factor for oesophageal adenocarcinoma. Barrett’s Oesophagus is hypothesised to arise from chronic long-term gastric reflux where the contents of the stomach flow back up the oesophagus. Approximately 12% of oesophageal adenocarcinoma patients were diagnosed with Barrett’s before their cancer diagnosis but approximately 57% of oesophageal carcinoma patients are diagnosed with Barrett’s simultaneously with their cancer diagnosis. This highlights the close link between these diseases. It is important to note not all patients will progress to cancer, but treatment is crucial to manage symptoms and prevent progression. In this blog, I will discuss the various treatment options available. On the island of Ireland, treatment is similar in the Republic and in Northern Ireland with both following the guidelines set out by the British Society of Gastroenterology. These are summarised in the figure below:
Barrett’s is classified using a 5-point scale (or the Vienna Grade classification system) summarised in the table below. Dysplasia refers to the growth of abnormal cells. When patients are first diagnosed, they are prescribed proton-pump inhibitors and are encouraged to consider lifestyle and dietary changes to limit reflux. These include maintaining a healthy weight to decrease pressure on the stomach, adjusting their sleep position to elevate their head and avoiding lying down for 2 hours after meals. Similarly, avoiding spicy, fatty and acidic/tomato-based foods in their diet can help. In addition, patients are advised to limit caffeine, alcohol and smoking to alleviate their symptoms. Proton pump inhibitors are tablets which patients take to reduce the production of acid from the stomach. This limits the exposure of the oesophagus to acid and decreases inflammation, providing symptomatic relief.
Barrett’s progression is monitored by regular camera tests or endoscopes where doctors will pass a camera down the oesophagus. During this procedure, they also collect biopsies or pieces of tissue, and these are examined under the microscope for abnormal cells. If patients have abnormal cells which is known as progression to dysplasia, endoscopic eradication therapies are used to remove the diseased tissue. The most common method used is Endoscopic Mucosal Resection (EMR) followed by ablation. EMR is performed during an endoscopy exam. Essentially, the dysplastic tissue is lifted away from the oesophagus. This is done by injecting a small amount of liquid under the abnormal cells. These cells are then removed using a suction device. Ablation usually accompanies this technique to ensure complete removal. Radio Frequency Ablation is the most common ablation technique. It uses heat to burn away the diseased tissue, promoting the growth of healthy tissue. Cryotherapy is sometimes used instead of Radio Frequency Ablation in other countries. The principle is the same, but this time uses very cold gases to burn away the diseased tissue.
For patients with high-grade dysplasia or early oesophageal cancer, surgical procedures such as oesophagectomy or Nissen Fundoplication are considered. An oesophagectomy is a serious surgical procedure where the diseased area of the oesophagus is removed. The stomach and small intestine are then rearranged or pulled upwards to compensate for this. Nissen Fundoplication is a procedure used to treat severe reflux where the top of the stomach is wrapped around the lower oesophagus. This reinforces the oesophageal sphincter muscle, preventing reflux.
Ongoing research in many labs and centres around the world are investigating Barrett’s and innovative alternative methods to treat this disease. There are promising advances being made in the field of genetics and biomarkers where patients are screened for certain genes or proteins which might indicate progression. These so-called biomarkers or signatures highlight to doctors which patients are at a higher risk for progression and may require more regular checkups or endoscopes. The capsule sponge test has also been developed which can be used to collect cells from the oesophagus preventing patients from the ordeal of an endoscope. Here, patients swallow a capsule attached to a string. Inside the capsule, is a tiny sponge. Once the capsule reaches the stomach, the capsule melts releasing the sponge, and the doctor/nurse gently pulls the string to bring the sponge back up the oesophagus. As it migrates upwards, the sponge collects cells along the oesophagus. These can be examined under the microscope to check for abnormal cells.
With monitoring and adherence to medical advice, Barrett’s can be effectively managed to relieve symptoms and reduce the risk of progression to cancer. More research has increased our knowledge on the disease and together with improvement in current therapies and the prospect of new therapies, the outlook for those with Barrett’s Oesophagus continues to improve.
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