Barrett’s esophagus and esophageal cancer

People who suffer from Barrett’s disease have an increased risk of developing esophageal cancer. Barrett’s esophagus always starts at the bottom of the esophagus, where it joins the stomach. 30 to 50% of all Barrett patients have an increased risk of esophageal cancer. Still, because it is a rare disease, the chance of developing esophageal cancer is quite low.

What is Barrett’s Esophagus?

A healthy esophagus has a layer of pearly-colored mucous membrane around it. This mucous membrane is called squamous epithelium in the medical world. Some people have pink gastric mucosa in the lower part of the esophagus, where it joins the stomach. This does not mean that they have Barrett’s disease, if the mucous membrane otherwise looks normal. With Barrett’s esophagus, an abnormality can be seen in the mucous membrane. The mucous membrane near the stomach is abnormally pink in color and looks very different under the microscope than normal pink mucous membrane. The mucosa of Barrett’s esophagus contains intestinal metaplasia. Because this is not an abnormality that can be traced with the naked eye, it is necessary to examine a piece of the esophagus under the microscope to determine whether someone indeed has Barrett’s disease.
The size of the piece of Barrett’s mucosa varies per patient. Medically they speak of a short piece when the Barrett’s mucosa is shorter than 3 centimeters. Many people with Barrett’s disease also suffer from a hiatal hernia. In the medical world this is also called diaphragmatic hernia. A hiatal hernia is not necessarily caused by Barrett’s esophagus. There are also people who have a hiatal hernia, but not Barrett’s esophagus.
There is a higher risk of cancer developing in Barrett’s mucosa than in other mucous membranes. The cancer that develops as a result of Barett’s is also called adenocarcinoma. After the 1970s, this form of cancer increased sharply, especially in the US and Western Europe. Approximately 800 new patients are added every year. This reaches a percentage of 60% of all cases of esophageal cancer in the Netherlands. People with Barrett’s esophagus are 30 to 50% more likely to develop adenocarcinoma than healthy people.

How does Barrett’s disease develop?

Barrett’s esophagus is caused by reflux disease over a number of years. Reflux disease means that the stomach contents flow back into the esophagus. The stomach contents contain acid and bile, which damage the lining of the esophagus. This causes esophageal infections. People who have suffered from severe reflux disease for years, approximately 10% of all patients with reflux disease, develop Barrett’s disease. After years of irritation and damage to the mucosa, the healthy mucosa is replaced by the abnormal Barrett’s mucosa. The Barrett’s mucosa is more resistant to the acid and bile from the stomach, but it has not yet been scientifically proven that this is actually the cause of the development of Barrett’s. Some people with Barrett’s esophagus actually have fewer complaints as a result of heartburn, which is very harmful to normal mucous membranes. Other patients have the same complaints. It is therefore unknown why some people with severe reflux disease develop Barrett’s esophagus and others do not.
The lower sphincter of the esophagus, also called the LES, acts as a closing valve between the stomach and the esophagus. Due to the pressure on this valve, it closes and prevents the contents of the stomach from flowing back into the esophagus. People with reflux suffer from periods of lower pressure, which means that the valve does not close properly and the stomach contents can flow back. People with severe reflux disease have constant too low pressure on the closing valve or sphincter of the esophagus, which allows the stomach contents to flow back into the esophagus at all times.

Delayed gastric emptying

When the stomach is unable to quickly process the food and transport it to the intestines after a meal, there is delayed gastric emptying. This can be a cause of reflux disease and reflux disease can in turn cause Barrett’s. In patients with delayed gastric emptying, the pressure in the stomach is increased. When the pressure on the closing valve of the esophagus is reduced, the pressure of the stomach becomes greater than that of the closing valve. This allows the stomach contents to flow back into the esophagus.

The diagnose

It is not easy to properly determine whether someone indeed has Barrett’s disease, or Barrett’s esophagus. The reason for this is that there are no clear symptoms of Barrett’s. It is known that reflux disease is more common in people with Barrett’s esophagus than in people who do not have Barrett’s. However, not everyone with reflux disease necessarily has Barrett’s. That is why Barrett cannot be diagnosed solely through the diagnosis of reflux disease. To diagnose Barrett’s disease for sure, it is necessary to remove a piece of the esophagus and view it under a microscope.
Because many people do not go to a doctor for heartburn (which can indicate reflux disease), it often happens that people suddenly develop adenocarcinoma after years of complaints, even though they have never heard of Barrett’s esophagus.

Barrett’s treatment

Many people with Barrett’s take acid-blocking medication or undergo anti-reflux surgery. Yet it has never been proven that the medication or surgery completely eliminates the disease or reduces the risk of adenocarcinoma (cancer).
The only method that has been proven to completely eliminate Barrett’s , and thus cure it, is surgical removal of the esophagus. This operation is only performed in patients with cancer or high-grade dysplasia (troubled cells). This operation is not recommended for people who only have Barrett’s disease. This is because the risks of the operation are quite high and it is a very major operation. Research has shown that not all Barrett patients actually develop cancer, which is why doctors have decided not to remove the esophagus of all Barrett patients as a precaution. However, they must have regular endoscopy performed to monitor the development of Barrett’s and thus any cancer.

New treatment

A new form of treatment has been adopted for Barrett’s esophagus. This treatment is the endoscopic removal of the Barrett’s mucosa and can be applied to some (not all) patients. The Barrett’s mucosa is removed or destroyed via an endoscope. Destruction is done by burning away the mucous membrane. Because this treatment is still relatively new, it is not yet used by all doctors and not on all patients. The treatment is now only applied to patients with an early stage of cancer and high-grade dysplasia. People who want to undergo this treatment, but do not have high-grade dysplasia or cancer, should consider the treatment experimental. If this treatment is successful, the patient is prescribed acid-blocking medications that should completely heal the esophagus. It has not yet been proven whether this new treatment can indeed completely (and permanently) cure Barrett’s and reduce the risk of cancer.

Barrett’s esophagus and cancer

Barrett’s esophagus has nothing to do with heredity. Research has shown that 3 to 5% of all Barrett’s patients eventually develop cancer. It is unknown why one patient develops cancer and another does not. The size of the Barrett’s mucosa also has nothing to do with the development of cancer. Some patients with a relatively short piece (less than 3 centimeters) can develop cancer, while patients with a much larger piece do not. The length of the Barrett’s segment therefore does not determine the risk of cancer. If cancer does develop in the esophagus, there is a high risk of metastasis to other organs, such as the liver and lungs. In patients who are in good physical condition (in addition to the cancer), it is therefore recommended to have the esophagus completely removed. However, the cancer cannot be cured in all cases, even due to possible metastases. People who have an advanced form of esophageal cancer often have problems swallowing. In many of these cases, a tube is inserted through the nose into the stomach to administer food and fluid. Some tumors can still be burned or excised.

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