Virginia Mason is an internationally recognized center for the diagnosis and treatment of esophageal disorders, including gastroesophageal reflux disease (GERD) and Barrett's esophagus. Barrett's esophagus is a disorder of the lining of the lower esophagus caused by persistent gastroesophageal reflux disease or GERD. GERD is the backward flow of stomach acid into the esophagus, which causes a sour taste and a burning sensation in the throat.
About one in 10 individuals who have GERD will go on to develop Barrett's esophagus. Screening and prevention are important aspects of care because individuals with Barrett's are at a significantly higher risk of developing esophageal cancer. Barrett's esophagus is monitored regularly with endoscopic surveillance and biopsy.
The esophagus is a thin muscular tube that carries food from the mouth to the stomach. A band of tissue, called the lower esophageal sphincter (LES), prevents stomach contents and acid from flowing back up into the esophagus. In severe gastroesophageal reflux disease (GERD), the LES malfunctions, allowing a backflow of stomach contents and acid into the lower esophagus. Over time, persistent GERD can cause inflammation and damage to the cellular lining in the esophagus, which may lead to the development of Barrett's esophagus.
A Spectrum of Cellular Changes
Barrett's esophagus lies on a spectrum of cellular changes that can occur within the esophageal lining. The presence of Barrett's tissue itself is a precancerous condition. However, more cellular changes can occur within the Barrett's tissue: low-grade or high-grade dysplasia. Each is also a precancerous condition, with high-grade dysplasia representing a higher likelihood that the cellular changes taking place will lead to esophageal cancer.
Barrett's esophagus is diagnosed using an endoscope, which is a thin flexible tube that contains miniaturized instruments, including a camera or ultrasound probe. After the patient receives a topical medication to numb the throat and a mild sedative, a gastroenterologist gently guides the endoscope down the esophagus and into the stomach, and takes images that are transferred to a video monitor. Your gastroenterologist also is able to take tissue samples (biopsy) through the endoscope. This procedure is called upper gastrointestinal endoscopy (upper GI) with biopsy or esophagogastroduodenoscopy (EGD) with biopsy.
Barrett's esophagus appears reddish in color rather than the normal pink of healthy tissue. Barrett's esophagus may affect a small "column" of tissue or a larger portion of the esophageal lining.
While there is no formal recommendation for screening for Barrett's esophagus, it is widely recommended by gastroenterologists that individuals who require daily acid-suppression medications or who are experiencing noticeable heartburn two or more times per week, should be evaluated with an endoscopic procedure at least once to determine if they have Barrett's esophagus.
Patients found to have Barrett's esophagus are recommended to undergo surveillance endoscopy and biopsy at three-year intervals.
If no cellular changes (called dysplasia) have occurred within the Barrett's tissue, the condition is treated with preventive lifestyle measures and control of reflux disease, along with endoscopic surveillance and biopsy every three years. Controlling gastric reflux - stomach acid that flushes back up into the lower esophagus - is vital in preventing further damage to the esophageal lining.
Preventive measures include:
- Treating esophageal reflux disease (GERD)
- Avoiding acidic as well as fatty fried foods
- Avoiding caffeine, alcohol and tobacco products that can irritate the esophagus
- Avoiding lying down after eating
- Losing weight
- Sleeping with the head of the bed elevated
If a biopsy shows cellular changes within Barrett's tissue, your physician will recommend that you undergo a procedure to have the damaged esophageal tissue removed.
Ablation Measures and Surgery
Ablation is a medical term that means removal or eradication of tissue. Endoscopic ablation therapy for Barrett's esophagus is a minimally invasive procedure that removes diseased cells in the mucosal layer of the esophagus. The removal is done by means of an endoscope and a treatment modality such as cryotherapy, photodynamic therapy or radiofrequency ablation.
The type of treatment chosen for patients is determined on a case-by-case basis, taking into consideration several factors, including how long the Barrett's segment is within the esophagus, the patient's own symptoms, and his or her capability for follow-up treatment. Patients undergoing treatment also will continue lifestyle changes and drug therapy for reflux disease.
In more advanced cases, surgery to remove a layer of mucosal tissue lining the esophagus or to remove part of the esophagus itself may be required.
Virginia Mason has the most advanced, minimally invasive procedures available for treatment of Barrett's esophagus.
Cryotherapy - also referred to as cryo-ablation, cryosurgery or cryospray - is the use of extreme cold to destroy diseased tissue. Cryotherapy is often chosen by gastroenterologists because it allows them to reach difficult-to-treat areas within the esophageal lining, and is a relatively quick, outpatient procedure for patients with few side effects.
During this procedure, patients are first given a mild sedative. Your gastroenterologist then gently maneuvers an endoscope down the esophagus. The endoscope contains a catheter and a miniature camera, which allows your doctor to view images of the diseased area on a video monitor.
Once the treatment area is identified, liquid nitrogen or argon gas is sprayed through the catheter at a low pressure onto the segment of the esophageal lining that has Barrett's esophagus. The frozen tissue is allowed to thaw and then is sprayed again. The treatment freezes and kills the diseased cells, allowing regeneration of new healthy cells. The procedure takes about 20-30 minutes. Several treatments over several months may be performed.
After the procedure, patients may experience minor swallowing difficulties for a few days. However, most patients are able to go back to work the following day. Patients have a regular follow-up visit with their gastroenterologist after the procedure.
Photodynamic therapy is the use of laser light in combination with a light-sensitive drug, called Photofrin, to destroy diseased tissue. Patients are given an injection of the light-sensitive drug two days before their treatment. This drug is "taken up" in the diseased tissue. On the day of treatment, and after first receiving a mild sedative, the laser light at the end of an endoscope is applied to the area. The light activates the drug and kills diseased cells without affecting normal tissue. The treatment is done as an outpatient procedure and can be repeated as needed. It takes about 45 minutes.
Photodynamic therapy is used in patients with Barrett's esophagus with low- or high-grade dysplasia, and in patients with early or advanced esophageal cancer. Patients are able to eat a nearly normal diet within 4 to 5 days of treatment. Because a light-sensitive drug is used, patients will need to stay out of direct sunlight for four weeks after receiving this therapy.
Radiofrequency ablation is a treatment modality commonly used in cardiology to treat out-of-sync heartbeats, called tachyarrhythmias, as well as in other medical specialties. This same radiofrequency energy - similar to microwave energy - is used in Barrett's esophagus to destroy cells within the Barrett's tissue. After the patient has received a mild sedative, the gastroenterologist gently maneuvers an endoscope down the esophagus. The endoscope contains a catheter with an electrode at its tip and a small camera that sends images to a video monitor. When the area of the esophagus has been identified, the gastroenterologist directs the radiofrequency energy at the Barrett's segment to be treated. The heat energy destroys the diseased cells leaving healthy tissue untreated.
This minimally invasive treatment takes about 30 minutes and patients are able to resume their normal activities the following day. Some patients experience minor swallowing discomfort for several days.
Esophageal Mucosal Resection (EMR)
A mucosectomy is a procedure in which the top layer of esophageal tissue, called the mucosal layer, is removed by an endoscope. In time, another layer of tissue will grow back in its place. This procedure is often used in precancerous conditions, such as Barrett's Esophagus.
Before the procedure, the throat is sprayed with a local anesthetic. Patients also are given mild sedatives through an intravenous (IV) line. The endoscope is then guided into the esophagus and the area of Barrett's is carefully examined. The specific area, or mucosa, to be removed is raised away from the wall of the esophagus by injecting sterile saline under the mucosa. This area is removed with a snare-like instrument, which is passed through the endoscope.
The procedure is performed in the Endoscopy Suite in the Gastrointestinal Unit and takes about 30 to 45 minutes. After the procedure there is some discomfort in the throat, which lasts for a short period of time. Patients eat a soft diet for about three to four days following the procedure.
Endoscopic mucosectomy was first used to obtain a large biopsy sample of tissue in the esophagus or colon but later evolved into a treatment modality. Unlike therapy with a laser, which destroys tissue, the specimen is preserved and can be studied further by a pathologist.
Your gastroenterologist, in consultation with a Virginia Mason thoracic surgeon, may determine that the segment of the esophagus containing Barrett's tissue be removed. This surgery, performed in the operating room, is commonly done at Virginia Mason. In fact, Virginia Mason surgeons have achieved some of the best outcomes in the world for esophageal surgery.
During surgery, a portion of the esophagus is removed and the remaining esophagus is connected to the stomach, or is reconstructed using a portion of the stomach or large intestine. Esophageal surgery is an extensive surgical procedure. Your surgeon will discuss the details of your surgery with you and answer any questions you may have.