Hiatal Hernia
The esophagus empties food through the muscle that separates the chest cavity from the abdominal space called the diaphragmatic hiatus. When this hole becomes too large it is called a hiatal hernia. Anatomical abnormalities such as a hiatal hernia may also contribute to GERD. A hiatal hernia occurs when the upper part of the stomach and the lower esophageal sphincter (LES) move above the diaphragm, the muscle wall that separates the stomach from the chest.
Normally, the diaphragm helps the LES keep acid from rising up into the esophagus. When a hiatal hernia is present, acid reflux can occur more easily. A hiatal hernia can occur in people of any age and is most often a normal finding in otherwise healthy people over age 50. Most of the time, a hiatal hernia produces no symptoms.
Barrett’s Esophagus
Barrett's esophagus is a condition in which the esophagus, the muscular tube that carries food and saliva from the mouth to the stomach, changes so that some of its lining is replaced by a type of tissue similar to that normally found in the intestine. This process is called intestinal metaplasia or Barrett’s Esophagus.
While Barrett's esophagus may cause no symptoms itself, this process can increase the risk of developing esophageal cancer, and so once diagnosed, Barrett’s Esophagus must be carefully treated by an expert physician specialist. Barrett's esophagus is estimated to affect about 700,000 adults in the United States. It is associated with the very common condition gastroesophageal reflux disease or GERD. Between 2 and 15% of people with Barrett’s esophagus may develop cancer in their esophagus.
GERD and Barrett’s Esophagus
The exact causes of Barrett's esophagus are not known, but it is thought to be caused in part by the same factors that cause GERD. Acid washing from the stomach into the esophagus causes damage that left untreated, can cause Barrett’s. Although people who do not have heartburn can have Barrett's esophagus, it is found about three to five times more often in people with this condition.
Barrett's esophagus is uncommon in children. The average age at diagnosis is 60, but it is usually difficult to determine when the problem started. It is about twice as common in men as in women and is much more common in white men than in men of other races.
Barrett's Esophagus and Cancer of the Esophagus
Barrett's esophagus does not cause symptoms itself and is important only because it seems to precede the development of a particular kind of cancer—esophageal adenocarcinoma. The risk of developing adenocarcinoma is 30 to 125 times higher in people who have Barrett's esophagus than in people who do not. This type of cancer is increasing rapidly in white men. This increase may be related to the rise in obesity and GERD.
For people who have Barrett's esophagus, the risk of getting cancer of the esophagus is small – about 1 percent per year. Esophageal adenocarcinoma is often not curable, partly because the disease is frequently discovered at a late stage and because treatments are not effective.
Diagnosis and Screening
Barrett's esophagus can only be diagnosed by an upper GI endoscopy to obtain biopsies of the esophagus. At present, it cannot be diagnosed on the basis of symptoms, physical exam or blood tests. In an upper GI endoscopy, a flexible tube called an endoscope, which has a light and miniature camera, is passed into the esophagus. If the tissue appears suspicious, then biopsies must be done. A biopsy is the removal of a small piece of tissue using a pincher-like device passed through the endoscope. A pathologist examines the tissue under a microscope to confirm the diagnosis.
Looking for a medical problem in people who do not know whether they have one is called screening. Currently, there are no commonly accepted guidelines on who should have endoscopy to check for Barrett's esophagus. Among the many reasons for the lack of firm recommendations about screening are the great expense and occasional risk of side effects of the test. Also, the rate of finding Barrett's esophagus is low, and finding the problem early has not been proven to prevent deaths from cancer.
Many physicians recommend that adult patients who are over the age of 40 and have had GERD symptoms for a number of years have endoscopy to see whether they have Barrett's esophagus. Screening for this condition in people who have no symptoms is not recommended.
Treatment of Barrett's
What’s most important in treating Barrett's esophagus is a plan to reduce acid in the esophagus. While this can be done with drugs, the best way to reduce acid in the esophagus is to reconstruct the valve at the bottom of the esophagus where it enters the stomach. Besides controlling the acid, the Barrett’s can be removed or ablated with a variety of nonsurgical methods that can completely remove all the abnormal tissue in the esophagus. Gastrointestinal surgeons at Ohio State’s Medical Center helped develop the technique using an instrument called BarrX that can allow a normal esophagus to reform in place of Barrett’s esophagus. The procedure is done without surgery and requires only a brief outpatient procedure using a lighted scope placed into the esophagus from the mouth with the patient sedated. The procedure is safe and rarely has side effects. After treatment, routine follow up is still necessary and long-term outcomes are not yet known. Surgery is recommended only for people who have a high risk of developing cancer or who already have it.
Surveillance for Dysplasia and Cancer
Periodic endoscopic examinations to look for early warning signs of cancer are generally recommended for people who have Barrett's esophagus. This approach is called surveillance. When people who have Barrett's esophagus develop cancer, the process seems to go through an intermediate stage in which cancer cells appear in the Barrett's tissue. This condition is called dysplasia and can be seen only in biopsies with a microscope. The process is patchy and cannot be seen directly through the endoscope, so multiple biopsies must be taken. Even then, the cancer cells can be missed.
The process of change from Barrett's to cancer seems to happen in about 1 percent of patients per year. Most physicians recommend that patients with Barrett's esophagus undergo periodic surveillance endoscopy to have biopsies. The recommended interval between endoscopies varies depending on specific circumstances, and the ideal interval has not been determined. You should see a gastrointestinal specialist with experience treating patients with Barrett’s to ensure you get the best treatment for you.
Treatment for Dysplasia or Esophageal Adenocarcinoma
If a person with Barrett's esophagus is found to have dysplasia or cancer, the doctor will usually recommend surgery if the person is strong enough and has a good chance of being cured. The type of surgery may vary, but it usually involves removing most of the esophagus and pulling the stomach up into the chest to attach it to what remains of the esophagus. Many patients with Barrett's esophagus and dysplasia can be treated without major surgery; patients who are elderly or have many other medical problems that make surgery unwise can have other treatments as well. A gastrointestinal specialist with expertise in this area should decide on the best treatment plan based on the individual’s circumstances.
Learn more about treatment of esophageal cancers at Ohio State's James Cancer Hospital and Solove Research Institute
