Endobrachyösophagus; Barrett's esophagus

Barrett's syndrome: esophageal disease

Barrett's esophagus is a special disease of the esophagus, which usually occurs as a result of a reflux disease. Changes in the mucous membrane lead to a shortening of the esophagus. The transformed tissue carries an increased risk of cancer. Possible therapies are based on treatments for reflux and heartburn. If precancerous lesions have already been reached or if Barrett's carcinoma has developed, surgical procedures are used. An important role in cancer screening is the regular monitoring of Barrett syndrome by endoscopy and biopsy.

contents

• Barrett's syndrome: esophageal disease
• A short overview
• definition
• symptoms
• causes
• diagnosis
• treatment
• Naturopathic treatment
• Current state of research

A short overview

While the entire article provides comprehensive information about Barrett's esophagus, the following summary provides a quick overview of the key facts about this particular oesophageal disease:

• definition: Barrett's esophagus is an internal shortening of the esophagus caused by chronic reflux of gastric acid into the esophagus. This leads to specific changes of the mucosa on the esophageal inner wall.
• symptoms: Complaints do not always occur. Symptoms typically include heartburn, difficulty swallowing and pain or burning behind the sternum.
• causes: It is believed that chronic and severe reflux diseases lead to the specific tissue changes of the epithelial layer in the esophagus. Permanent irritation and inflammation favor the formation of a resistant columnar epithelium, which carries a higher risk of degeneration in itself.
• diagnosis: For a confirmed finding, endoscopic examinations, in particular an esophageal reflection, are performed. In addition, the stage of the disease and possible cancer precursors are determined by means of tissue samples.
• treatment: In the treatment, the type (length less than or over three centimeters) and the stage of Barrett's esophagus are crucial. First drug of choice are drug therapies. Surgery may be used in more severe cases, precancerous lesions or malignant carcinomas. Supportive natural remedies can be used. In any case, attention should be paid to the diet and a healthy lifestyle.

definition

As Barrett's esophagus (obsolete also endobrachyesophagus) is called an endoscopic (internal) shortening of the esophagus. This disease usually arises from a chronic reflux of gastric acid into the esophagus, which leads to a change of the mucosa on the esophageal inner wall. This tissue change is a metaplastic circular transformation of the epithelium of the lower esophagus. This, in turn, explains the internal shortening, because the transition between the stomach and the esophagus is shifted upward (upside down).

Barrett's esophagus is a serious disease of chronic reflux and carries an increased risk of developing kidney cancer. (Image: ipopba / fotolia.com)

A metaplastic transformation describes the process of changing one differentiated tissue type into another (metaplasia). In a healthy human, the oesophageal mucosa usually forms a multi-layered undyed squamous epithelium as the uppermost cell layer. This is replaced by a single-layered high-prismatic columnar epithelium (columnar epithelial metaplasia) in the development of Barrett's syndrome in the lower esophagus. The columnar epithelium corresponds to the typical epithelium of the intestinal mucosa and, unlike the squamous epithelium, forms goblet cells (specialized columnar epithelium). The columnar epithelium is more resistant to the existing irritation, but carries a higher risk of degeneration in itself.

In professional circles one speaks of a Barrett's esophagus in the strict sense, if it concerns a circular metaplasia, ie if the transition from the plate to the columnar epithelium (Z-line) in the direction of the oral cavity covers the entire circumference of the esophagus. In principle, a distinction is made between two variants: a short-segmented with a length of up to three centimeters (short-segment Barrett's esophagus) and a long-segmented with over three centimeters (long-segment Barrett's esophagus).

The disease is named after the Australian-British surgeon Norman Barrett (1903-1979). According to various studies, Barrett's esophagus is detected in one to four percent of gastroscopic examinations. Men are affected much more frequently than women.

The specific tissue changes of the epithelial layer are formed in Barrett's syndrome in the lower esophagus. (Image: bilderzwerg / fotolia.com)

symptoms

The process of tissue transformation normally does not involve any discomfort and in the further course of the disease affected individuals can remain symptom-free. Otherwise, the typical symptoms of existing Barrett's esophagus resemble the symptoms of possible previous illnesses. For example, gastroesophageal reflux disease, oesophagitis, and Barrett's syndrome have the following hallmarks:

• Acid regurgitation and heartburn,
• Pain or burning behind the sternum,
• Dysphagia (dysphagia).

sequelae

Pronounced dysphagia may also lead to weight loss in those affected. In addition, the risk of developing esophageal carcinoma due to a long-term or severe reflux disease increases. About 10 percent of those with Barrett's esophagus subsequently develop Barrett's carcinoma in the lower esophagus at the transition to the stomach (adenocarcinoma). This cancer forms from glandular cells of the mucous membrane. The degeneracy risk is generally higher in the long-segmented versions.

Another possible sequelae is ulcer formation (Barrett's ulcer). In addition, the inflammatory processes and scarring can also lead to a considerable constriction of the esophagus (esophageal stricture).

A typical symptom is heartburn, which also occurs in reflux diseases. (Image: Adiano / fotolia.com)

causes

Up to ten percent of sufferers with reflux disease also develop Barrett's syndrome. The reason for the occurring tissue change has not been finally clarified. Inflammations in the lower esophagus caused by steady reflux (reflux oesophagitis), in addition to permanent irritation, are also thought to cause certain signaling and regeneration disorders in the affected cells.

In addition to the harmful acidity of gastric juice, other external risk factors probably also play a role in the development of the disease, such as increased consumption of alcohol and nicotine. Also, the Barrett's esophagus a certain genetic predisposition is awarded.

diagnosis

For a safe diagnosis of Barrett's esophagus, an endoscopy is performed. In a single examination, not only the esophagus is examined endoscopically with a probe or a tube, but also the stomach (gaster) and the duodenum (duodenum). This is referred to by medical professionals as esophagogastroduodenoscopy, in common usage it is referred to as a reflection of the esophagus, the stomach and the intestine.

An additional removal of tissue samples (four quadrants biopsy) from conspicuous areas serves to differentiate between benign and malignant cell changes. A chromoendoscopy is often carried out beforehand in which special dyes used during endoscopy improve the diagnosis. The suspicious and conspicuously stained areas are sampled specifically for the subsequent histological examination.

checkups

If a Barrett's esophagus has been diagnosed, regular endoscopic check-up and tissue diagnostics are indispensable. However, there is no general consensus about the necessary frequency. Since the risk of degeneration in a short-segment Barrett syndrome according to experts is very low, this routine examinations are not necessarily necessary or only at longer intervals advised. In the case of a long-segment manifestation, there is a higher risk of the onset of cancer, which is why in these cases a (semi-) annual check is advisable first.

If there is no dysplasia (malformation and possible precancerous lesions), further controls may be less frequent (approximately every three years). Thus, the type and stage of Barrett's syndrome significantly determine the frequency of endoscopies and are to be determined by subject matter experts depending on the patient case. In the first year after the diagnosis, however, one to two check-ups always make sense.

Together with a biopsy, the endoscopic examination is used to ensure a reliable diagnosis. (Image: romaset / fotolia.com)

treatment

An existing Barrett's esophagus does not necessarily have to be treated as long as no malignant changes are detected. However, if symptoms arise, sufferers can be helped with treatments for the reflux disease.

While in light forms of reflux targeted dietary and behavioral changes can alleviate the symptoms, in the case of mucosal damage usually a drug treatment is necessary. At this stage, the first choice usually falls to so-called proton pump inhibitors such as omeprazole or pantoprazole. These drugs are designed to reduce or suppress the formation of stomach acid and thereby reduce the reflux and its harmful effects.

If drug therapy is unsuccessful or indicates other complications, surgery may be considered. So far, the so-called fundoplication (stomach cuff surgery) is most often used. This leads to over 90 percent of patients to a permanent cure of the reflux disease. Increasingly, however, other endoscopic anti-reflux therapies and the use of flexible magnetic tape as alternative surgical methods are also available. Relatively rarely is a photodynamic therapy carried out in which the Barrett's mucosa is to regress into the normal squamous epithelium by means of a laser treatment.

Considering cancer in the family and the results of the control studies, radiofrequency ablation (HALO ablation) may be advisable for the removal of Barrett's mucosa in cases of increased cancer risk.

When malignant changes in Barrett's esophagus (adenocarcinoma in the mucosa) is usually an endoscopic resection. During the endoscopic examination, the malignant tissue is sucked in and removed with a sling. This method offers many advantages over conventional surgical methodology. However, if the malignant lesions have penetrated into deep wall layers under the mucosa (submucosal layer), surgical intervention is necessary, which should be performed by experienced experts due to existing risks.

Regular follow-up is extremely important in Barrett's esophagus because of the increased risk of degeneration. (Image: Wolfilser / fotolia.com)

Naturopathic treatment

Possible measures from naturopathy promise effective support especially for mild symptoms of reflux disease and heartburn. But even with a Barrett's esophagus, alternative therapy methods can be an important part of the treatment. After surgical interventions, the supplementary procedures of aftercare can also serve to reduce the probability of recurrence.

Change of diet and lifestyle

A central role is played by targeted changes in lifestyle and eating habits. In particular, the following measures are important:

• Abstain from nicotine and alcohol,
• Reduction of overweight,
• regular and easy physical activity,
• Diet with a sufficient amount of fruits, vegetables and fiber,
• Avoidance of acidifying foods,
• Food without time pressure,
• Taking small meals,
• Digestive walks, do not lie down after eating,
• Sleep with upper body,
• stress reduction.

So far, there is little evidence of which foods in reflux most commonly cause discomfort. However, experience shows that acidic, sweet-and-sour, fatty, bitter and spicy (spicy and salty) foods have negative effects. These include coffee, chocolate and alcoholic beverages.

A deliberate change in lifestyle and diet can help alleviate discomfort and support post-operative follow-up. (Image: marilyn barbone / fotolia.com)

Alternative naturopathic procedures for reflux and heartburn

For self-medication for heartburn is often used in phytotherapy, the camomile application (Rollkur with chamomile tea). But other plants such as fennel, lemon balm, plantain and stinging nettle are suitable as natural herbal remedies.

Other options for counteracting acid regurgitation and reflux include homeopathic treatments, Schuessler salts, acupuncture and special home remedies.

Current state of research

From an initiative of physicians and scientists at various German university hospitals, a consortium has come together to explore the genetic causes of Barrett's esophagus and Barrett's carcinoma. The Barrett Initiative and the Barrett Consortium provide their own publications and other recent findings from research and public practice. (tf, cs; updated on 12.11.2018)

Additional Information:

Gastroesophageal reflux disease (reflux)
Esophagitis (Esophagitis)
heartburn

Specific information portals to Barrett's esophagus:

Barrett Initiative e.V..
Gastroenterology, Digestive and Metabolic Diseases - Guidelines Gastroesophageal Reflux Disease
Gastro-Liga - Guide to the esophagus / swallowing apparatus