Barrett's oesophagus

The oesophagus is the muscular tube that carries food from the mouth to the stomach. In Barrett's oesophagus, there are changes in the cells on the inner lining of the lower end of the oesophagus.

These cells normally look flat and are called squamous cells. But if you have Barrett’s oesophagus, the cells look column-shaped, like cells in the stomach or bowel.

Dysplasia

Barrett's oesophagus is not cancer. But over time, cell changes may mean they start to grow more abnormally. This is called dysplasia.

Dysplasia can be either:

• low grade – this means the cells are slightly abnormal
• high grade – this means the cells are more abnormal.

Sometimes the dysplasia develops into a cancer called adenocarcinoma of the oesophagus. This is a type of oesophageal cancer that develops from cells called glandular cells. Cancer develops when the normal workings of a cell go wrong and the cell becomes abnormal. The abnormal cell may keep dividing to make more and more abnormal cells. These can form a lump, called a tumour.

Fewer than 1 in 100 people in the UK (less than 1%) have Barrett's oesophagus. And very few people with Barrett’s oesophagus develop cancer. About 3 in 100 people who have Barrett's oesophagus (3%) develop oesophageal cancer.

Gastro-oesophageal reflux disease (GORD)

The main cause of Barrett’s oesophagus is gastro-oesophageal reflux disease (GORD).

In some people, the valve that joins the oesophagus to the stomach is weak. This means stomach juices and acid come up into the oesophagus. This is called gastro-oesophageal reflux disease (GORD).

GORD is very common, and many people have symptoms at some point in their lives.

Risk factors

Your risk of developing reflux is bigger if you:

• are overweight
• smoke
• drink too much alcohol
• eat spicy, acidic or fatty foods
• have a hiatus hernia.

A hiatus hernia is when part of the stomach moves up through the diaphragm, into the chest space. The diaphragm is the sheet of muscle that divides the tummy area (abdomen) from the chest. It helps keep acid and bile in the stomach.

Acid made by the stomach can come through the stomach valve and into the oesophagus. In some people, the acid can irritate the oesophagus, causing pain and heartburn. The changes to cells in Barrett’s oesophagus are caused by contact with acid during reflux over a long time.

Not everyone with acid reflux develops Barrett's oesophagus. About 5 in 100 people with acid reflux (5%) develop Barrett's oesophagus. It is more likely to develop in people who have had severe reflux for many years. It is also more common in:

• people who smoke
• men
• people aged over 50.

Barrett’s oesophagus is managed differently for each person. Your condition may be monitored regularly. Or you may have treatment. Your specialist doctor or nurse will talk to you about the options.

The aim of treatment for Barrett’s oesophagus is to reduce acid reflux and control symptoms. You may have an operation to strengthen the valve at the bottom of the oesophagus. Or you may have surgery to remove the affected area.

Surveillance

You might be monitored regularly. This means having regular endoscopies and biopsies to check for any changes in the cells. This is called surveillance. Your specialist doctor will talk to you about the benefits and disadvantages of surveillance.

The aim of surveillance is to find early changes to cells (dysplasia) that may develop into cancer. You can then have treatment to reduce the risk of cancer developing. Sometimes surveillance finds cancer in the very early stages, when treatment can be given to cure it.

How often you have endoscopies depends on whether the cells are changing and how quickly. Some people have an endoscopy every 2 years, and some have one every 3 months. Your specialist doctor will explain how often you need to be monitored.

If your symptoms get worse or you have any new symptoms between appointments, contact your doctor. Do not wait until your next appointment.

Reducing acid reflux

Lifestyle changes

Sometimes it is possible to reduce acid reflux by making some lifestyle changes. You could try the following:

• eat small meals during the day
• do not eat for 2 to 3 hours before bedtime
• raise the head end of your bed by 10 to 20cm if you have reflux at night. This will position your stomach below your chest and head, so acid cannot travel upwards. You can do this by putting something under your bed or mattress
• avoid spicy or fatty foods and alcohol. These may make symptoms worse
• keep to a healthy weight. If you are overweight, it may help to lose some weight
• if you smoke, stop smoking.

Medicines to reduce stomach acid

You may have drugs to reduce the amount of acid the stomach makes. This helps reduce the symptoms of gastro-oesophageal reflux disease (GORD). The 2 main drugs are:

• proton pump inhibitors (PPIs)
• histamine receptor blockers.

These are usually given as a tablet that you take every day. When the symptoms are controlled, your specialist doctor may lower the dose of your drugs to the lowest level that stops the symptoms. You may take PPIs for the rest of your life. Your doctor can explain the benefits of this and whether it is right for you.

Fundoplication

This is an operation that can help improve symptoms of GORD. It may be done to:

• repair a hiatus hernia
• strengthen the valve at the bottom of the oesophagus.

During surgery, the surgeon wraps the top of the stomach (the fundus) around the lower end of the oesophagus. They then stitch it in place. This strengthens the valve at the lower end of the oesophagus. It should help reduce acid reflux.

Fundoplication is often done using keyhole surgery. This means the surgeon uses a fine tube called a laparoscope. Using a laparoscope means the surgeon can make a few small cuts in the tummy (abdomen), rather than one big one. You may need to have a bigger cut for your operation. This is called a laparotomy. Your surgeon will explain what type of surgery you will have.

Removing the affected area

Sometimes a biopsy shows there are continuing changes in the cells. This may mean there is a risk these might develop into cancer. Your specialist doctor may suggest treatment to remove the affected area. This can be done in different ways. You may have one treatment or a combination of treatments.

This type of surgery is usually done at a specialist centre. This means you may have to travel further to have the operation.

Endoscopic mucosal resection (EMR)

The aim of an EMR is to remove the affected area of the oesophagus lining, without damaging the rest of the oesophagus. The surgeon removes the affected area using a thin wire called a snare. They put the snare through an endoscope into the body.

We have more information about EMR. This is mainly written for people with oesophageal cancer but the treatment and the side effects of EMR are the same for people having it for Barrett's oesophagus.

Radiofrequency ablation (RFA)

RFA uses heat to destroy abnormal cells. Your doctor uses an endoscope to pass a probe called an electrode down the oesophagus. The probe gives an electrical current (radiofrequency) to the abnormal area. The electrical current heats the abnormal cells to a high temperature. This destroys (ablates) them.

You usually have this treatment under a general anaesthetic. Or you may have a local anaesthetic and some medicine to make you drowsy (sedation). RFA is done at specialist centres, so you may have to travel for treatment.

The main side effects can include mild pain or discomfort. You will be given painkillers to help with this. You might feel generally unwell and have a high temperature for a few days.

Your cancer doctor can tell you more about possible side effects.

Oesophagectomy

This is an operation to remove part of the oesophagus. Your surgeon may offer you this operation if:

• you have a high-grade dysplasia
• you have a high-grade dysplasia that cannot be removed using an endoscope.

The surgeon removes the part of the oesophagus that contains the abnormal cells. They then join the stomach to the remaining part of the oesophagus. After this operation, you will probably spend a short time in the intensive care unit. You will have a drip put into a vein in your hand or arm until you can eat and drink again.

You may also have a fine tube inserted up the nose and down into the stomach or small intestine. This is called a nasogastric (NG) tube. It removes digestive fluids. This helps the area heal and can stop you feeling sick.

To start with, you may feel scared to swallow. You may also have a bad taste in your mouth. Mouthwashes can help with this.

You will probably only have sips of liquid until the join in the oesophagus has started to heal. It will be a few days before you can drink normally. You may have an x-ray to check the join is healed before you start eating. You will start with small amounts of soft food and build up slowly to eating normally again.

Sometimes the surgeon puts a small feeding tube directly into the small intestine during the operation. This is to feed you while you recover. They can remove it when you are getting enough nutrition by eating normally. This can take a few weeks. Your cancer doctor will talk to you about whether you might need a feeding tube.

We have more information about the side effects and recovery after an oesophagectomy. This information is for people who have oesophageal cancer, but the side effects and recovery are the same as people having it for Barrett's oesophagus.

Newer treatments for Barrett’s oesophagus

Other ways of treating Barrett's oesophagus are being researched. These include:

• multipolar electrocoagulation
• cryotherapy.

These treatments are only available as part of a clinical trial. Your specialist doctor can tell you more about these and whether there may be a trial suitable for you.