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BARRETT'S ESOPHAGUS

Barrett's esophagus is a condition that develops in some people who have chronic gastroesophageal reflux disease (GERD) or inflammation of the esophagus (esophagitis). In Barrett's esophagus, the normal cells that line the esophagus, called squamous cells, turn into a type of cell not usually found in humans, called specialized columnar cells. These cells become more like those cells that line the intestines in an attempt to become more resistant to acid.  Damage to the lining of the esophagus--for example, by acid reflux from GERD--causes these abnormal changes.  People who have had regular or daily heartburn for more than 5 years may be at risk for Barrett's esophagus and should discuss the possibility with their doctor. Symptoms include waking during the night because of heartburn pain, vomiting, blood in vomit or stool, and difficulty swallowing. . However, the diagnosis of Barrett's esophagus is often difficult because it often doesn't exhibit specific symptoms. Instead, the only obvious way of finding Barrett's esophagus is to thoroughly investigate the symptoms of acid reflux in appropriate individuals.

Men are more likely to develop Barrett's esophagus than women.  One in one hundred adults over the age of sixty have the condition.  However, Barrett's esophagus is often found in much younger individuals. The changes found in Barretts esophagus are  a precursor of cancer of the lower esophagus, known as adenocarcinoma. Cancer of the upper esophagus (squamous cell cancer) is usually linked to alcohol and tobacco use.  This type of cancer appears to be decreasing in the American population, while the rate of adenocarcinoma is increasing sharply, especially in white males. This drives many young individuals with chronic reflux symptoms to undergo endoscopy - since this is really the only way to diagnose the condition.

Looking at the lining of the esophagus with upper endoscopy and taking a biopsy to examine a sample of tissue are essential to making a diagnosis of Barrett's esophagus. The biopsy will be examined in a lab to see whether the normal squamous cells have been replaced with columnar cells.  Once the cells in the lining of the esophagus have turned into columnar cells, they will not revert back to normal. In other words, at this time, there is no cure for Barrett's esophagus. The earlier dysplasia is detected, the better the prognosis. Barrett's esophagus develops in grades ranging from noticeable changes (low-grade dysplasia) to very serious precancerous/early cancerous changes (high-grade dysplasia) and finally to invasive cancer. Detection of high-grade dysplasia is serious. Often, in such instances, cancer is already present. 

The goal of treatment is to prevent further damage by stopping any acid reflux from the stomach. Medications that are helpful include H2 receptor antagonists (or H2 blockers) and proton pump inhibitors, which reduce the amount of acid produced by the stomach.  Surgery to reduce a pre-existing hiatal hernia may also help in the long run.  The surgery, which is more and more often done in a minimally invasive way using the laparoscope (laser surgery), brings the herniated stomach back into the abdomen and fixes it there so the valve which holds acid and bile in the stomach is more effective. Despite the procedure providing symptomatic relief, this type of surgery rarely results in the regression of Barrett's esophagus. The risk of cancer remains, therefore aggressive endoscopic screening with biopsies is still recommended.

Sometimes the damaged lining of the esophagus becomes thick and hardened, causing strictures, or narrowing of the esophagus. Strictures can interfere with eating and drinking by preventing food and liquid from reaching the stomach. Strictures are treated by dilation, in which an instrument gently stretches the strictures and expands the opening in the esophagus. 

Patients with cancer of the esophagus who are candidates for surgery, or those with Barrett's esophagus and high-grade dysplasia, usually undergo a procedure in which the esophagus is removed completely and the stomach is pulled into the chest (esophagectomy). Because of the risk of esophagus cancer, people with Barrett's esophagus are screened for esophageal cancer regularly, usually with endoscopy and biopsy every one to two years.