Barrett’s Esophagus
Barrett’s Esophagus
Abstract & Commentary
Synopsis: This elegant review puts Barrett’s esophagus in clinical perspective. Written by an expert, Barrett’s esophagus is described in detail, including endoscopic and histopathologic recognition, epidemiology, and current management.
Source: Spechler SJ. N Engl J Med. 2002;346:836-842.
Barrett’s esophagus is a specialized columnar metaplasia of the squamous mucosa of the esophagus, thought to be associated with development of adenocarcinoma in as many as 0.4-0.5% of cases/year. Long-segment Barrett’s (> 3 cm) is found in 3-5% of endoscopies for chronic reflux symptoms, and short-segment Barrett’s occurs in 10-15% of patients. Barrett’s esophagus occurs mostly in Caucasian men in whom frequency of this cancer has quadrupled over a few decades. Controversy exists as to whether an extremely short segment of this mucosa has the same risk as classical long-segment Barrett’s. Endoscopy has been advocated to screen for Barrett’s, hoping that this might decrease the risk of death from cancer: particularly in obese white males aged older than 50 with symptoms over 5 years duration. However, such screening won’t have much effect on cancer death rates since 40% of patients with esophageal adenocarcinoma have no history of reflux at all. Studies of surveillance have not demonstrated any decrease in death rate in those surveyed. Costs of surveillance are high, and the absence of demonstrable benefit has led some to urge against routine surveillance in any group.
Although it might seem reasonable to treat Barrett’s patients with aggressive acid suppression to diminish cancer risk, there is no evidence that maximal acid suppression or antireflux surgery have any effect on cancer progression. Low-grade dysplasia cannot be reliably determined in biopsy material from Barrett’s mucosa, and natural history of low-grade dysplasia is uncertain. If screening is undertaken, finding of high-grade dysplasia is supposed to lead to esophagectomy, ablation therapy, or perhaps to intensive further surveillance. Esophagectomy is the only option shown to prevent the progression of dysplasia to cancer, but it has a mortality of 3-12% and 30-50% have serious operative complications.
Many gastroenterologists and the major GI societies propose that surveillance of Barrett’s esophagus should be done every 2-3 years. Low-grade dysplasia is thought to warrant repeated endoscopy at 6 and 12 months, then yearly if no further dysplasia is found. Dr. Spechler believes that data warrant surveillance done at 5-year intervals in Barrett’s without dysplasia, but he seems to agree with the other recommendations despite his own caveats that they are only poorly supported by "hard data." Dr. Spechler currently believes that ablative therapy should only be done in conjunction with controlled study protocols.
Comment by Malcolm Robinson MD, FACP, FACG
It seems critical to remember that no current approach to Barrett’s esophagus has been validated by any study demonstrating prolongation of survival or improved quality of life. Moreover, the rule in medicine to "first do no harm" does not seem to be upheld by our currently approved management recommendations for Barrett’s screening or the suggested interventions based on findings from such screening.
Dr. Robinson, Medical Director, Oklahoma Foundation for Digestive Research; Clinical Professor of Medicine, University of Oklahoma College of Medicine, Oklahoma City, OK, is Associate Editor of Internal Medicine Alert.
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