Pre-malignant condition characterized by conversion of the normal esophageal nonkeratinized squamous epithelium into metaplastic nonciliated columnar epithelium with goblet cells.
Barrett esophagus is a condition in which intestinal metaplastic columnar epithelium replaces the stratified squamous epithelium that normally lines the distal esophagus. The condition develops as a consequence of chronic gastroesophageal reflux disease (GERD) due to lower esophageal sphincter (LES) dysfunction. | Barrett Esophagus: Jorge Muniz, PA-C
Contents
Pre-malignant condition characterized by conversion of the normal esophageal nonkeratinized squamous epithelium into metaplastic nonciliated columnar epithelium with goblet cells.
Only known precursor to adenocarcinoma
Etiology
Risk factors:
Chronic oesophageal reflux (GERD) (>60% of cases)
Congenital retardation syndromes (1%)
Non-steroidal anti-inflammatory drugs (1%)
Chemotherapy (<1%)
Viral oesophagitis (<1%)
Disease progression:
The standard and alternative models of progression of Barrett’s oesophagus to adenocarcinoma of the oesophagus. The standard pathway to cancer is through the oesophagitis-metaplasia-dysplasia-adenocarcinoma sequence. Recently, however, it has been recognised that submucosal glands can also develop into metaplastic cells (alternative pathway A). In addition, squamous oesophagitis can conceivably develop directly into adenocarcinoma via “microscopic metaplasia” without apparently transitioning through endoscopically evident metaplasia (alternative pathway B). The column on the left shows the environmental factors that help facilitate progression of the Barrett’s oesophagus. The column on the right shows the genetic (blue) and epigenetic (red) changes in the evolution of cancer. APC, adenomatous polyposis coli gene | Jankowski, J., Barr, H., Wang, K., & Delaney, B. (2010). Diagnosis and management of Barrett’s oesophagus. BMJ (Clinical Research Ed.), 341, c4551–c4551. https://doi.org/10.1136/bmj.c4551
Progression of disease, demonstrating changes observed as esophagitis (A) undergoes metaplasia, leading to salmon-colored mucosal changes in the distal esophagus characteristic of Barrett’s esophagus (B) Dysplasia develops (C). | Modiano, N., & Gerson, L. B. (2007). Barrett’s esophagus: Incidence, etiology, pathophysiology, prevention and treatment. Therapeutics and Clinical Risk Management, 3(6), 1035–1145. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/18516262
Barrett Esophagus and Risk of Esophageal Cancer | Tsakiridis, K., Mpakas, A., Kesisis, G., Arikas, S., Argyriou, M., Siminelakis, S., Zarogoulidis, P., Katsikogiannis, N., Kougioumtzi, I., Tsiouda, T., Sarika, E., Katamoutou, I. and Zarogoulidis, K. (2014) ‘Lung inflammatory response syndrome after cardiac-operations and treatment of lornoxicam’, Journal of Thoracic Disease; Vol 6, Supplement 1 (March 2014): Journal of Thoracic Disease (Cardiothoracic diseases closely related from diagnosis to treatment). Available at: http://jtd.amegroups.com/article/view/2102.
Diagnosis
Algorithm for diagnosis, surveillance and management of patients with BE according to the American College of Gastroenterology Guidelines (2008). (A) Endoscopic detection of BE as salmon-coloured mucosal changes in the distal esophagus, characterized by the presence of tongues radiating from the gastroesophageal junction. (B) A biopsy specimen of intestinal metaplasia (arrow points to goblet cell). | Conteduca, V., Sansonno, D., Ingravallo, G., Marangi, S., Russi, S., Lauletta, G., & Dammacco, F. (2012). Barrett’s esophagus and esophageal cancer: An overview. International Journal of Oncology, 41, 414-424. https://doi.org/10.3892/ijo.2012.1481
Histopathologic features of the natural history of Barrett’s esophagus (BE). Progressive transition from squamous epithelium to intestinal metaplasia, dysplasia and adenocarcinoma (AC). Panel A, normal stratified squamous epithelium. Panel B, BE without dysplasia, with the presence of goblet cells. Panel C: BE with low-grade dysplasia. Panel D: BE with high-grade dysplasia. Panel E: AC. | Conteduca, V., Sansonno, D., Ingravallo, G., Marangi, S., Russi, S., Lauletta, G., & Dammacco, F. (2012). Barrett’s esophagus and esophageal cancer: An overview. International Journal of Oncology, 41, 414-424. https://doi.org/10.3892/ijo.2012.1481
Endoscopy: Prague criteria
Schematic representation according to Prague criteria and endoscopic images of BE. Panel A, endoscopic detection of BE, showing an area classified as C2M5. Both the maximal length (M) (including tongues) of BE and the length of the circumferential Barrett segment (C) are measured during endoscopy. These numbers can then be used to track the length of the Barrett segment. Panels B and C, endoscopic pictures of BE radiating tongues from the gastro-esophageal junction in a patient previously treated for GERD. Panels D and E, endoscopic white light imaging and magnification x1.5 of dysplastic BE from the same patient. Panel F, high resolution endoscopy with Narrow Band Imaging. A clear demarcation line is seen between the mucosa with irregular microvessels and irregular structural pattern, suggestive of dysplasia, and the non-dysplastic BE with regular microvessels and regular microstructural pattern. | Conteduca, V., Sansonno, D., Ingravallo, G., Marangi, S., Russi, S., Lauletta, G., & Dammacco, F. (2012). Barrett’s esophagus and esophageal cancer: An overview. International Journal of Oncology, 41, 414-424. https://doi.org/10.3892/ijo.2012.1481
Management
Chemoprevention and therapy in patients with BE and high-grade dysplasia. Possible preventive and therapeutic approaches that can be used in patients with high risk of developing AC. Few and uncontrolled studies have been carried out so far on their efficacy. In particular, comparative evaluations among these procedures are lacking. | Conteduca, V., Sansonno, D., Ingravallo, G., Marangi, S., Russi, S., Lauletta, G., & Dammacco, F. (2012). Barrett’s esophagus and esophageal cancer: An overview. International Journal of Oncology, 41, 414-424. https://doi.org/10.3892/ijo.2012.1481
Available radiofrequency ablation devices (RFA) include a circumferential device that can be used for ablation of large areas and focal devices comprising a paddle that can either be attached to the tip or placed through the working channel of an upper endoscope. | Medtronic
Improvement after radiofrequency ablation of Barrett’s esophagus. | Department of Digestive Tract Disease, Medical University of Lodz, Poland.
