Narrator: Coming up on Mayo 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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