Barrett's oesophagus: early diagnosis and treatment

By Cristiano Antonino On Jan 27, 2023

Barrett’s oesophagus is a disease of the oesophagus that involves alteration of the oesophageal mucosa, most often related to reflux of gastric acid juice (gastro-oesophageal reflux disease – GERD)

This alteration, also called intestinal metaplasia (‘metaplasia’ from the Greek for ‘transformation’), is a reversible state, but, if left untreated, can become in a fortunately modest proportion of patients a precancerous condition (first low-grade and then high-grade dysplasia) and over the years turn into a malignant neoplasm.

Barrett’s oesophagus, in whom is the disease found?

Barrett’s oesophagus has a prevalence of between 0.5% and 2% of the adult world population.

In particular, it is frequently found in:

men of Caucasian ethnicity;
aged between 50 and 60 years;
patients with long-standing gastro-oesophageal reflux (often unaware of and/or symptomatic for such reflux).

To give some numbers, it suffices to mention that between 5 and 15% of symptomatic gastro-oesophageal reflux disease patients have Barrett’s Oesophagus and that this, in turn, increases the risk of developing oesophageal neoplasia between 30 and 120 times higher than in the general population.

The manifestation of reflux disease is vague and with a poor clinical picture of symptoms

These when present are the so-called typical symptoms

retrosternal heartburn (burning);
epigastric discomfort (sometimes after eating, sometimes on an empty stomach);
postprandial heaviness;
sensation of acid reflux sometimes going straight back into the mouth.

Sometimes the symptomatology includes so-called atypical symptoms, which are often overlooked by the patient himself such as:

cough;
hoarseness;
sore throat in the morning.

It is precisely because of these indirect and vague signs of gastro-oesophageal reflux disease that patients often obtain a diagnosis late, risking that the picture, where not known, will present itself at an advanced stage.

For an initial diagnosis of Barrett’s oesophagus, the patient should undergo

gastroscopy (EGDS);
biopsies of the dysplastic mucosa and, if present, of the lesions.

It is a good idea to refer to a centre with a high level of expertise, both in endoscopy and in pathological anatomy, so that the picture is not confused with oesophagitis or other rarer diseases of the oesophagus.

Classification and treatment of Barrett’s oesophagus

The classification of Barrett’s oesophagus is based on the so-called Prague classification.

This is an endoscopic classification, therefore carried out during the EGDS, which allows its extent to be quantified, both in terms of its circumference (C) and the distance of its upper edge (M).

When faced with such a suspicion, the expert endoscopist will have to take mucosal biopsies according to a very precise protocol (Seattle protocol with a large number of samples taken in the 4 quadrants at different levels on the oesophagus) in order to obtain histological confirmation of the Barrett suspicion,’ the specialists continue.

These biopsies will be analysed by an anatomic pathologist, an expert in the management of these cases, who will formulate a precise diagnosis of the state of the mucosa.

Thus, either only intestinal metaplasia can be confirmed, or lesions that are increasingly suspicious in a degenerative sense, ranging from low-grade to high-grade dysplasia to adenocarcinoma of the oesophagus, can be highlighted.

The transformation of such lesions from intestinal metaplasia to oesophageal adenocarcinoma may be a very slow process over the years, but it must be intercepted, diagnosed and treated.

This is why a multidisciplinary approach to the disease is essential, involving the gastroenterologist, endoscopist and anatomopathologist alongside the surgeon.

The latter is also the central specialist in the treatment of the patient who has progressed from Barrett’s oesophagus to oesophageal cancer, and this treatment pathway also involves other professional figures, namely the oncologist, radiotherapist, radiologist, nuclear physician and nurse navigator.

Depending on the classification, Barrett’s oesophagus can be treated with multiple approaches:

pharmacological therapy with pump inhibitors and endoscopic follow-up;
surgical treatment with anti-reflux plastic: Barrett’s is associated with gastro-oesophageal reflux disease (GERD) and anti-reflux plastic decreases/shuts down the damaging effect of gastric acid on the oesophagus;
endoscopic treatment, through ablation (superficial burn) or removal (EMR – ESD) of the damaged part of the mucosa.

Nutrition and Barrett’s oesophagus

There is no specific diet for the prevention or treatment of Barrett’s oesophagus.

We therefore refer to a diet/diet that counteracts gastro-oesophageal reflux and thus inflammation of the oesophagus.

It is also necessary to have dietary-behavioural habits that can help in controlling reflux.

These include:

avoiding large meals
eating a low-fat diet;
eating slowly, chewing well;
not going to bed after eating;
avoiding food that is too hot or cold;
do not smoke and do not drink alcohol.

Neoplastic development: diagnosis and treatment

Once a diagnosis of suspected Barrett’s oesophagus has been made, biopsies highlight the presence or absence of neoplastic lesions and, if so, stratify the risk of evolution.

If a diagnosis of adenocarcinoma of the oesophagus is confirmed, the patient must be taken into the care of the multidisciplinary team, which draws up a personalised treatment algorithm.

A number of in-depth investigations, such as echo-endoscopy, chest-abdomen CT scan, MRI and PET scan, will be carried out, and based on the preoperative staging, the treatment course will be decided.

The creation of Multidisciplinary Teams dedicated to the pathology has allowed a sharing of ideas, scientific knowledge and therefore decisions, which undoubtedly leads to a better treatment opportunity for the patient.

The task of the multidisciplinary team is also to get the patient to the operation in the best possible condition, both from a nutritional point of view and in terms of physical performance status, and therefore the taking charge of the patients by the physiotherapist and nutritionist is fundamental.

Once all pre-operative investigations have been completed, the patient may be a direct candidate for oesophagectomy surgery or, in most cases, for chemotherapy or chemoradiotherapy treatment prior to surgery.

The intent of such treatment, if indicated, is to reduce the size of the neoplastic lesion and any enlarged lymph nodes that may be present, so as to have better control of the disease and decrease the risk of distant recurrence.

Oesophagectomy surgery

Oesophagectomy surgery is one of the most complex operations of the digestive system.

It involves the removal of part of the stomach and part of the oesophagus together with the regional lymph glands, with the remaining portion of the oesophagus and the portion of the stomach that has been preserved being ‘tubulated’ and transposed to the thorax.

Because of the anatomical location of the stomach and oesophagus, this operation requires an abdominal and a thoracic phase and can be performed by the traditional route in open surgery, but today mainly by the minimally invasive route, i.e. by laparoscopy (in abdominal time) and thoracoscopy (in thoracic time).

Following the operation, the patient, after a few days in which artificial nutrition guarantees the caloric intake, can resume eating by mouth by modifying his or her habits a little.

The diet must be fractioned with small, frequent meals, 5/6 times with several snacks interspersed throughout the day and less abundant main meals.

After a few months, the patient’s quality of life is excellent and there are no limitations.

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