Barrett’s oesophagus

This information has been written by staff working in the Endoscopy Unit at Chelsea and Westminster Hospital. If, after you have read it, you have any questions or concerns, please call us on our direct line 020 3315 3056/5223.

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What is Barrett’s oesophagus?

Barrett’s oesophagus is a condition which affects the oesophagus (the food pipe connecting the mouth to the stomach). In Barrett’s oesophagus the lining of the oesophagus has changed from a pinkish white appearance to a reddish discolouration which is seen at endoscopy.

What causes Barrett’s oesophagus?

Barrett’s oesophagus is thought to occur due to excess acid reflux in the stomach. This causes the cells which normally line the oesophagus to be replaced by those which normally line the stomach.

What causes the reflux?

It is thought that the acid reflux is caused by a weakened sphincter at the bottom of the oesophagus. It is not clear how this happens, however some risk factors which are thought to contribute include:

• Obesity
• Smoking
• Alcohol
• Hiatus hernia

Some individuals may not have the above risk factors and still develop Barrett’s oesophagus.

Why is Barrett’s oesophagus important?

Barrett’s oesophagus can predispose an individual to oesophageal cancer—although it is important to realise that fewer than 1 in 20 patients with Barrett’s oesophagus go on to have cancer of the oesophagus over their lifetime. In order to try to detect the presence of pre-cancerous changes early and provide treatment it is important to monitor patients with Barrett’s oesophagus. This is done by enrolling them into the Barrett’s surveillance program at this Trust.

What does the Barrett’s surveillance programme entail?

Enrolling into the surveillance programme means having regular endoscopy tests. How often these are done depends on a number of factors and will be decided individually. Endoscopy is a tool used to identify patients with Barrett’s, and to look for any suspicious changes in the lining of the oesophagus. The aim of the endoscopy is to find abnormal cells early before they develop into oesophageal cancer.

Endoscopy is a generally safe procedure but there is a small risk of complications. These are an extremely small risk of bleeding (haemorrhage 1 in 1,000) or a tear of the gut (perforation 1 in 9,000). These may require urgent treatment, blood transfusion or surgical operation.

During the procedure, the endoscopist will usually take several biopsies from the abnormal area. This can take time, so we would recommend that patients have sedation for the procedure to improve their experience. If you do have sedation, you will need an escort to take you home after. In addition, because multiple biopsies are taken to detect any cell changes, please let the endoscopy staff know at the time of booking if you have been started on any blood thinning tablets such as aspirin, clopidogrel, or warfarin.

What will happen after the endoscopy?

The biopsy tissue from the test will be examined under a microscope to confirm the diagnosis of Barrett’s oesophagus and to look for any precancerous changes. A letter detailing the results of the endoscopy and microscopy results will then be sent to you and your GP. This letter will detail if any further treatment is needed and when your next surveillance endoscopy is planned.

What if my results show pre-cancerous cells?

If precancerous cells are found, then the term dysplasia will be used, along with a grading of either low grade or high grade. This does not mean that a cancer diagnosis has been made, however samples with high grade dysplasia are much more likely to turn cancerous.

An appointment will normally be made to discuss these results with you and the treatment options available. Treatment can usually be offered by a further endoscopy to remove the abnormal cells (endoscopic resection), or burning off the abnormal areas in a technique called radio-frequency ablation. As these treatments are not currently offered at our Trust, we would refer you to a specialist if needed.

What if my results do not show pre-cancerous cells?

Even if no precancerous cells are found, there is still a risk of this developing in the future. The aim of Barrett’s surveillance is to identify these precancerous cells early, therefore you will still be invited to have regular endoscopy tests. The interval of which this will occur will be decided after your biopsy results has been reviewed along with how much of the lining of the oesophagus has been affected with Barrett’s oesophagus.

Although the aim of the endoscopy surveillance is to find abnormal areas of Barrett’s early on, there is no guarantee that having regular endoscopy surveillance will detect all cancers at an early stage. Rarely, cancers can develop between one surveillance endoscopy and the next one. Current guidelines do not recommend surveillance for patients with short segments of Barrett’s (<3 cm) if the cell type is not concerning. In these cases you may be discharged back to your GP with advice.

How can I reduce the risk of oesophageal cancer developing?

We will ask your GP to prescribe regular acid suppressing medication such as omeprazole. You should continue taking these even if you have no reflux symptoms. You can also take steps to reduce the risk of oesophageal cancer developing:

• Stop smoking
• Reduce alcohol intake
• Avoiding late night snacks before bedtime (to reduce the risk of acid reflux)
• Weight loss to a healthy body mass index

There are no precise dietary recommendations for patients with Barrett’s oesophagus. However, you should avoid foods if they make your reflux or heartburn symptoms worse. For example, an excess of alcohol, coffee, chocolate and citrus fruits all fall into this category. Fatty foods also tend to take longer to leave the stomach and this can make patients feel uncomfortable. If you find that large meals irritate your Barrett’s, then eating smaller amounts more often might suit you better.

What are the surgical options for Barrett’s oesophagus?

Some patients with Barrett’s oesophagus may be recommended to have surgery to tighten the junction between the stomach and oesophagus. However surgery for Barrett’s oesophagus is quite intensive, it is therefore only recommended for a small group of patients after review of lifestyle measures and medical options.

What if I don’t want regular endoscopy tests or cannot have endoscopy tests?

Although endoscopy is a safe procedure, there can be some serious complications. As a result, surveillance endoscopy is not recommended for some patients with severe heart or chest problems, or increased frailty in the elderly. You may also decide that you do not want to have regular endoscopy tests.

At the time of your initial diagnosis of Barrett’s oesophagus we will aim to review you in endoscopy or clinic to discuss the risks versus the benefits of doing endoscopy surveillance, and give you our recommendations.

If you choose not to have regular endoscopy tests, we would normally advise you to look for the following symptoms:

• Worsening reflux
• Difficulty swallowing
• Weight loss

If you have any of those symptoms, ask to see your GP urgently. Your GP can then refer you back to the gastroenterology team.