Mayo Clinic Q&A

On the Mayo Clinic Q&A podcast, Dr. James East, a gastroenterologist at Mayo Clinic Healthcare in London, discusses diagnosing and treating Barrett’s esophagus.

Show Notes

Barrett's esophagus is a condition in which the lining esophagus becomes damaged by acid reflux, which causes the lining to thicken and become red. Over time, the valve between the esophagus and the stomach may begin to fail, leading to acid and chemical damage of the esophagus, a condition called gastroesophageal reflux disease, or GERD.  In some people, GERD may trigger a change in the cells that line the lower esophagus, causing Barrett's esophagus.

"The stomach is well designed to handle highly acidic conditions," explains Dr. James East, a gastroenterologist at Mayo Clinic Healthcare in London. "But the esophagus is not designed to cope with acid. And so when acid comes up, that acid reflux damages the cells, replacing them with more acid-resistant cells that develop into Barrett's esophagus." 

While frequent heartburn may be a sign, many people with Barrett’s esophagus have no symptoms. Having Barrett's esophagus does increase your risk of developing esophageal cancer. Although the cancer risk is small, it's important for people with Barrett's esophagus to have regular checkups to check for precancerous cells. 

Those at highest risk for Barrett's esophagus include: 

  • White men over the age of 50.
  • People with family history of Barrett's esophagus or esophageal cancer.
  • People who smoke. 
  • People with excess abdominal fat. 
  • Patients with long-standing reflux lasting more than five years. 
"If you have three of those risk factors, then you should have a screening endoscopy for Barrett's esophagus, according to current guidelines," says Dr. East. 

To screen for Barrett's esophagus, a lighted tube with a camera at the end, called an endoscope, is passed down the throat to check for signs of changing esophagus tissue. A biopsy is often done to remove tissue and confirm the diagnosis.

Treatment for Barrett's esophagus depends on the extent of abnormal cell growth in your esophagus and your overall health. Treatments in the early stages can include lifestyle measures and medications to help reduce acid reflux and therefore, the esophageal acid exposure. 

If the cell damage is more extensive, radiofrequency ablation may be be used. In this technique, a balloon is used to heat the abnormal esophagus tissue and burn it away. Another technique, cryotherapy, applies cold liquid or gas to destroy the abnormal cells.

The best way to prevent Barrett's esophagus is to address acid reflux and GERD through lifestyle changes.

"Lifestyle measures that reduce the risk of reflux are the key here because once Barrett's esophagus develops, it's a permanent change unless we use some of the ablation techniques," says Dr. East. "So absolutely quit smoking, and limit alcohol and caffeine. And even losing a small amount of weight can really help reduce reflux symptoms."

On the Mayo Clinic Q&A podcast, Dr. East discusses diagnosing and treating Barrett’s esophagus. 

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Clinic Q&A...

Dr. James East: So Barrett's is
related to chronic acid damage,

where recurrent burning of the
lower esophagus by acidic

reflux, those cells are
pre-malignant and increase your

risk of developing esophageal
cancer.

Narrator: Barrett's esophagus is
a condition in which the pink

lining of the esophagus
connecting the mouth to the

stomach becomes damaged by acid
reflux. Medications and

lifestyle changes can reduce the
risk of damage and the chances

of developing cancer.

Dr. James East: I think
lifestyle measures that reduce

the risk of reflux are the key
here because once Barrett's

esophagus develops, it's a
permanent change unless we use

some of the ablation techniques.
Stopping smoking, alcohol,

caffeine, some medications that
can reduce lower esophageal

sphincter pressure, losing even
quite a small amount of weight

can really help reduce reflux
symptoms.

Jason Howland: Welcome everyone
to Mayo Clinic Q&A. I'm Jason

Howland sitting in today for Dr.
Halena Gazelka. Barrett's

esophagus is a condition in
which the lining of the

esophagus becomes damaged by
acid reflux. This causes the

lining to thicken and become
red. While frequent heartburn

may be a sign, many people with
Barrett's esophagus have no

symptoms. Having Barrett's
esophagus does increase your

risk of developing esophageal
cancer. Although the risk is

small, it's important to have
regular checkups to check for

precancerous cells. Joining us
today to discuss diagnosing and

treating Barrett's esophagus is
Dr. James East. He is a

gastroenterologist at Mayo
Clinic Healthcare in London. Dr.

East, welcome back to the
program.

Dr. James East: Jason, thank
you. Great to be back.

Jason Howland: Well, let's start
off first by talking about how

common is Barrett's esophagus
for people that maybe have never

heard of it.

Dr. James East: So Barrett's
esophagus, in the whole

population, maybe about one to
one and a half percent of the

population have Barrett's
esophagus, but it's not evenly

distributed. It mainly occurs in
patients who have symptoms of

gastro esophageal reflux
disease, or GERD. And in that

population who have reflux
symptoms, maybe five to 15% of

those patients have Barrett's
esophagus.

Jason Howland: What causes it?

Dr. James East: So Barrett's, as
you've alluded to, is related to

chronic acid damage, where
recurrent burning of the lower

esophagus by acidic reflux
damages the cells, which are

then replaced by more
acid-resistant cells. That's the

Barrett's esophagus. That's
good, because it stops hurting.

But it's bad, because those
cells are pre-malignant and

increase your risk of developing
esophageal cancer.

Jason Howland: And for people
that are familiar, acid reflux,

is it the same thing as
heartburn? Or is it something

different?

Dr. James East: So acid reflux
can present with a range of

symptoms, heartburn is one of
them. But people can also have

chest pain, they can sometimes
have trouble swallowing, a

feeling of a lump in the throat,
or some slightly more unusual

symptoms related to reflux high
up in the throat, where patients

can have maybe a chronic cough
or a worsening of their asthma.

Jason Howland: And essentially
it is the stomach's acid is

coming up to where it's not
supposed to be, right?

Dr. James East: Indeed. So the
lower esophageal sphincter, so

that's the ring of muscle that
is at the bottom of the gullet

and compresses and stops the
content of the stomach, which is

acidic, coming up into the
esophagus. The stomach is well

designed to handle highly acidic
conditions. But the esophagus is

not designed to cope with acid.
And so when acid comes up, it

forms a burn and can and that
damage, as it repairs, can

develop into Barrett's
esophagus.

Jason Howland: So who is at risk
for Barrett's esophagus?

Dr. James East: So again, the
risk is not evenly distributed

in the population. People who
are at more at risk, men are at

greater risk than women,
particularly Caucasian men,

older men, over 50. Patients
with long standing reflux, maybe

for more than five years. People
who smoke, people who are

overweight, and patients who
have a family history of either

Barrett's esophagus, or
esophageal adenocarcinoma,

that's the cancer that comes
from Barrett's esophagus. And in

fact, if you have three of those
risk factors that I've just

described, then probably you
should have a screening

endoscopy for Barrett's
esophagus, according to current

guidelines.

Jason Howland: We mentioned it
earlier, but can you talk a

little bit more about the link
between Barrett's esophagus and

esophageal cancer?

Dr. James East: So Barrett's
esophagus is thought to be the

first stage in the cellular
changes that progress slowly

towards esophageal cancer. It's
after patients develop Barrett's

esophagus, they can then develop
low grade dysplasia, so early

precancerous change, that
progresses to high grade

dysplasia, and in sequence then
progresses to Barrett's

esophagus with acquiring a
sequence of genetic changes that

make it more likely to develop
into cancer, over time.

Jason Howland: As a
gastroenterologist, how do you

diagnose Barrett's esophagus?

Dr. James East: So the standard
method to diagnose Barrett's

esophagus is currently to have a
gastroscopy, an upper GI

endoscopy. Where with a thin
flexible telescope, with a light

and a video chip on the end, we
can look down very gently into

the gullet and see the changes
of Barrett's esophagus.

Normally, we would take biopsies
as well to send off to the lab

to confirm the diagnosis.

Jason Howland: So you're able to
get a very clear picture with

this.

Dr. James East: Absolutely. With
modern high-definition

endoscopes, we can see very
nicely where the bottom of the

esophagus or sometimes we see a
small hiatus hernia, where that

ends, and then we see darker red
tongues of the Barrett's

esophagus extending up against
the rather paler pink

appearances of the normal
esophageal lining.

Jason Howland: So if someone is
diagnosed with Barrett's

esophagus, how do you go about
treating it?

Dr. James East: So I think that
there are a number of things.

First, lifestyle measures,
stopping smoking, reducing

alcohol, maybe trying to lose
some weight, and these are

primarily thinking about things
that will reduce reflux and

esophageal acid exposure. In
terms of medication, this is

also focused on reducing
esophageal acid exposure and

commonly proton-pump inhibitors.
So these are medicines like

omeprizale or lansoprezole are
now recommended, with the idea

to completely abolish all reflux
symptoms, with the idea that if

we're not damaging the
esophagus, we're not promoting

that cell turnover that leads to
progression toward precancerous

changing to cancer. Finally,
there's been some recent work,

though it's now more established
in clinical practice, about now

trying to eradicate Barrett's
esophagus. And the most frequent

technique used for this is
called radiofrequency ablation.

Where a balloon is used to heat
the lining of the esophagus

press tightly against it over
the Barrett's area. And this

just makes it burn, maybe half a
millimeter in depth, that

destroys the Barrett's. And when
it regrows, hopefully it grows

back as the normal esophageal
lining with a lower cancer risk.

Jason Howland: That specific
treatment is that a recent

advance in treatment, and are
there any other recent advances

in diagnosing or treating
Barrett's esophagus?

Dr. James East: So, thinking
about diagnosis. First, there's

been a non-endoscopic mechanism
for diagnosing Barrett's

esophagus that's been explored
quite a bit during COVID. This

is called cytosponge. It looks
like a large tablet on a string

that you swallow it and when it
reaches the stomach, the capsule

that it's in dissolves, and it
looks like one of those buzzy

toothbrushes and you pull the
string out and it scrapes the

cells off the bottom of the
esophagus, and those can be

analyzed to see if they have
changes associated with

Barrett's. We've also seen the
use of advanced endoscopic

imaging techniques like
narrowband imaging that can show

superficial blood vessels, and
in combination with

magnification, can help doctors
target the biopsies to the

highest risk areas. In terms of
treatment, we've talked about

radiofrequency ablation with a
balloon that heats the very

superficial layers of the
esophagus and destroys them. But

equally, techniques like
cryoablation, which instead uses

freezing to get rid of those
superficial cellular layers, are

also now available to remove
small sections of the esophagus

with a banding technique that
that avoids the need for more

invasive surgery, though this is
a subspecialist technique.

Jason Howland: It's all
fascinating stuff. I guess we're

just about out of time. But
lastly, is there anything that

people can I do to prevent
Barrett's esophagus? I know you

mentioned some of the lifestyle
factors such as smoking and some

of the others. What can we do to
prevent getting Barrett's

esophagus?

Dr. James East: I think
lifestyle measures that reduce

the risk of reflux are the key
here because once Barrett's

esophagus develops, it's a
permanent change unless we use

some of the ablation techniques
that we've previously discussed.

So absolutely, smoking, alcohol,
caffeine, some medications that

can reduce lower esophageal
sphincter pressure are all

important changes, but
particularly perhaps, in the

sort of current climate, losing
even quite a small amount of

weight can really help reduce
reflux symptoms.

Jason Howland: All right, well,
thank you so much. We are all

out of time. But our thanks
today to gastroenterologist, Dr.

James East for joining us today
from Mayo Clinic Healthcare in

London. Thank you, Dr. East.

Dr. James East: Pleasure.

Jason Howland: And thank you for
joining us here on Mayo Clinic

Q&A. Have a great day.

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