Barrett's Oesophagus

What is Barrett's oesophagus?

Barrett's oesophagus means some of the cells lining your food pipe (oesophagus) have changed and started to look more like the cells that line your stomach or bowel. It's usually caused by long-term acid reflux and is described as a potentially precancerous condition: in a small number of people, the abnormal cells develop into oesophageal cancer over time, but most people with Barrett's never do.

What are the symptoms of Barrett's oesophagus?

Barrett's oesophagus doesn't cause symptoms of its own. Many people are only diagnosed when they have tests for something else, or during investigation of long-standing reflux. The main symptoms people notice are those of the reflux (GORD) that usually causes it:

• heartburn (a burning feeling behind the breastbone)
• regurgitation, where food or acid comes back up into your throat or mouth
• a sore throat or a metallic taste in your mouth
• difficulty or pain when swallowing.

Reflux symptoms are often worse lying down, and waking at night with reflux is a particularly strong risk indicator. Confusingly, some people with Barrett's have a less sensitive oesophagus and notice fewer symptoms than before, even though the underlying damage is ongoing; treating your own symptoms with over-the-counter antacids without seeing a doctor can mask this and delay diagnosis.

See your doctor for persistent indigestion or heartburn that doesn't go away, and as soon as possible if you have any of the following, which can be signs the condition has progressed:

• increasing difficulty or pain swallowing
• frequent regurgitation or vomiting after eating or drinking
• unexplained weight loss
• vomiting blood, or black, tarry stools
• a hoarse voice or other voice changes
• unusual tiredness (which can be a sign of anaemia).

What causes Barrett's oesophagus, and who's at risk?

The exact cause isn't known, but Barrett's is strongly linked to long-term gastro-oesophageal reflux disease (GORD), where stomach acid and other digestive juices repeatedly wash up into the oesophagus. Over time, this can injure and inflame the lining (oesophagitis); as it heals, the cells sometimes change to a type that better resists this repeated damage, in the same way the stomach and bowel lining is normally more resistant to acid. Between roughly 6 and 15 in 100 people with GORD go on to develop Barrett's, and the risk rises the longer and more often reflux symptoms occur.

You may be more likely to develop Barrett's if you:

• are male (it's around 2 to 3 times more common in men, and particularly common in white men)
• are older, typically over 55
• have a family history of Barrett's oesophagus
• carry excess weight, particularly around your waist
• smoke
• have a hiatus hernia, where part of the stomach moves up into the chest
• regularly drink alcohol, or eat a diet high in salted, smoked or pickled foods.

A diet rich in fruit, vegetables and fibre, along with regular physical activity, appears to lower the risk.

Are there different types of Barrett's oesophagus?

Barrett's is classified in two main ways. By length, it's described as short-segment (affected tissue less than 3cm long) or long-segment (3cm or more); your endoscopy report may also describe this using a scoring system called the Prague classification, which records both the overall length of the affected area and how far it extends all the way round the oesophagus.

By cell changes, it's staged as:

• no dysplasia: the cells have changed (metaplasia) but show no pre-cancerous features, meaning a low cancer risk
• low-grade dysplasia: the cells show early pre-cancerous changes
• high-grade dysplasia: the cells show more significant pre-cancerous changes and a higher cancer risk.

How is Barrett's oesophagus diagnosed?

Barrett's is usually diagnosed by endoscopy (sometimes called gastroscopy): a thin, flexible tube with a camera is passed down through your mouth (or occasionally your nose, a newer and potentially more comfortable option) to examine your oesophagus directly, usually with sedation or a local anaesthetic spray. Barrett's tissue typically looks red and slightly coarse, compared with the normal pale pink, smooth lining. Since the change doesn't affect the whole oesophagus evenly, several small tissue samples (biopsies) are usually taken from different areas and checked under a microscope to confirm the diagnosis and look for dysplasia.

A newer test, called a capsule sponge test (brand names include Cytosponge and EndoSign), is available in some parts of the UK, particularly for people with persistent reflux symptoms. You swallow a small capsule attached to a thread; it dissolves in your stomach after several minutes, releasing a gelatine-coated sponge, which a nurse then gently pulls back out through your mouth. The sponge collects cells from your oesophagus lining on the way out, which are then checked in a laboratory. If changes are found, you'll still need an endoscopy to confirm the diagnosis.

How is Barrett's oesophagus treated?

Treatment depends on whether dysplasia (pre-cancerous cell changes) is present.

Barrett's without dysplasia

This carries a low cancer risk, and treatment focuses on controlling reflux rather than removing the Barrett's tissue itself:

• proton pump inhibitor medicines (such as omeprazole or lansoprazole) reduce stomach acid production; if you can't tolerate these, an alternative such as famotidine may be used, though it's usually less effective long-term
• lifestyle changes, including losing excess weight, drinking less alcohol, stopping smoking, eating smaller meals, and avoiding food for around 3 hours before bed
• surgery (a keyhole procedure called a Nissen fundoplication, which wraps the top of the stomach around the lower oesophagus) if medicines and lifestyle changes aren't enough to control symptoms.

It's important to keep taking any medicine you've been prescribed, since none of these treatments remove the underlying Barrett's change or fully eliminate the small cancer risk; that's why ongoing monitoring still matters even if you feel well.

Barrett's with dysplasia

Treatment approaches have changed significantly in recent years. Removing the oesophagus (oesophagectomy), once a common approach for high-grade dysplasia, is now mostly reserved for confirmed cancer; minimally invasive endoscopic techniques can usually treat precancerous changes and very early cancers instead. These include:

• endoscopic mucosal resection (EMR), which removes small areas of abnormal tissue for both treatment and more detailed assessment; risks include bleeding (around 1 in 50 procedures), a small hole forming in the treated area (around 1 in 200), and narrowing of the oesophagus afterwards (around 1 in 20), which can usually be treated by gently stretching it
• endoscopic submucosal dissection (ESD), a similar but more extensive technique for larger areas or early cancers, done under general anaesthetic
• radiofrequency ablation (RFA), which uses heat to destroy abnormal flat areas of tissue; it's now the preferred first treatment in the UK for high-grade dysplasia, and is approved for some cases of low-grade dysplasia too, often needing several sessions
• cryotherapy, which freezes abnormal cells instead; in the UK this is currently used mainly as part of research studies.

If low-grade dysplasia is found, you'll usually have a repeat endoscopy after 6 months to see whether it has settled or progressed, before deciding whether specialist treatment is needed. High-grade dysplasia usually leads to prompt referral to a specialist centre.

Ongoing monitoring

Barrett's tissue doesn't go away by itself, and can sometimes return even after treatment, so regular surveillance is usually recommended for as long as it remains likely to benefit you. Typical intervals (which your specialist will tailor to your own risk factors, including age, sex, smoking history and family history) are:

• every 2 to 3 years for long-segment Barrett's (3cm or more)
• every 3 to 5 years for short-segment Barrett's with cell changes (intestinal metaplasia)
• often no routine surveillance for short-segment Barrett's without intestinal metaplasia, as this isn't associated with an increased cancer risk, though the diagnosis is usually confirmed with 2 endoscopies first.

Some hospitals may offer the capsule sponge test as an alternative to endoscopy for surveillance.

When should you see a doctor?

See your GP if you have persistent indigestion or heartburn that doesn't go away. See a doctor as soon as possible if you develop difficulty or pain swallowing, food coming back up, unexplained weight loss, vomiting blood, black or tarry stools, a hoarse voice, or unusual tiredness, since these can be signs that need prompt investigation.