Questions & Answers About Barrett's Esophagus

I'm a 24-year old woman who was diagnosed with Barrett's Esophagus about six years ago. I took medication for this for about three years, but eventually the pain and heartburn returned. It was determined that I should undergo surgery to treat this, specifically a procedure known as a Nissen Fundoplication. Since then, I have not had the heartburn and pain I was having.

Recently, I've noticed a slight tightness in my chest and a little pain. My mother (who also has been diagnosed with this) told me that a new internist informed her that the surgery doesn't "cure" Barrett's and that I should still be checked regularly for this. I'm a little bit concerned since I haven't had an endoscopy in about three years. Do I have anything to worry about and should I be having endoscopies on a regular basis? Jennifer

Dear Jennifer,

As you know, Barrett's esophagus, sometimes called Barrett's epithelium, refers to a change in the lining of the lower esophagus where the normal pinkish lining (the epithelium) is replaced with a darker, red lining (this looks more like the stomach lining). It is necessary to biopsy this area because the increased chance of developing esophageal adenocarcinoma is present only if intestinal metaplasia (intestinal glands present on biopsies of the lower esophagus) is noted.

There is no routine modality that is used that has been proven to reverse or destroy Barrett's epithelium. Researchers have used specialized techniques such as bipolar electrocoagulation (cautery), photodynamic therapy and laser treatments to destroy Barrett's epithelium with variable success rates. Prolonged acid suppression (with omeprazole and lasoprazole) and Nissen fundoplication have not been consistently proven to alter Barrett's epithelium.

Therefore, it is recommended that you have surveillance endoscopies every two years or so if it is documented that you have intestinal metaplasia.

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For the past six months, I have been feeling that there is something stuck in my throat or larynx which causes no real pain but minor difficulties in swallowing. In addition, I frequently feel some pressure around my forehead and temples, which causes a little spaciness and difficulty in concentrating. I am wondering if these two symptoms are related.

I am 46 years old, a moderate tobacco and marijuana smoker, relative non-drinker with a bad diet that includes about two cups of strong coffee per day. After three visits to my community health clinic, where I was told I might have chest or throat cancer, I had a chest x-ray, which was negative and then went to an ENT, who diagnosed me with acid reflux, told me not to worry and suggested lifestyle changes. He shone a light down my throat, described it as red and swollen and wondered if I drank a lot or chewed tobacco. This was six weeks ago.

Since then, I've cut back on smoking and drinking, elevated my head in bed and am eating smaller, healthier meals. My condition is unchanged or slightly worse and I'm becoming annoyed. Is it possible I could have something stuck in my throat? I would like to know what's going on. Paul

Dear Paul,

There are several possible explanation for your symptoms. You may have a post-nasal drip or sinus causing your irritation. Esophageal reflux of acid can cause and sore throat and inflammation of the oropharynx (back of the throat). Lifestyle modifications, as you have done, improve symptoms in some people, but often medications (inhibitors of acid secretion, prokinetic agents) are necessary for complete relief. If possible, you should completely eliminate tobacco and coffee for several weeks to observe if there is symptom improvement. Finally, it is possible that you have an incoordination of the esophageal muscles that is causing the swallowing difficulty and sensation of something being stuck in your throat.

To exclude these various possibilities and to determine if there is specific therapy for your symptoms, you should be assessed by a gastroenterologist. If an upper endoscopy was not done, you should have this test. An esophageal motility study may also be necessary.

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I have GERD, a slight hiatal hernia and a recent endoscopy revealed Barrett's Epithelium. Is this different than Barrett's Esophagus? Also, I have been on 20 mg. of Prilosec daily for the past seven months and my doctor is continuing this indefinitely. I've read that there have been no studies regarding long-term use of Prilosec. Is this the best treatment for my condition? Tim

Dear Tim,

Barrett's epithelium is a term used to describe a change in the lining of the lower esophagus. Normally, the esophagus is lined by pink, squamous type epithelium (lining) and the stomach is lined by darker, reddish, columnar type epithelium. When the lower esophagus is damaged by acid, its pink lining can be replaced by the darker, reddish lining.

If the lining on biopsy appears more like the intestinal lining, it is called intestinal metaplasia. Intestinal metaplasia has been associated with the development of esophageal adenocarcinoma(cancer) of the lower esophagus. For all practical purposes, Barrett's esophagus and Barrett's epithelium are the same thing.

Omeprazole (Prilosec) has been used in patients with gastroesophageal reflux (GERD) in Europe for long periods of time (at least 3 to 5 years) without any apparent complications.

Although some studies have shown the regression of Barrett's epithelium with long-term use of this drug, I don't believe it occurs in most patients and I would not recommend its use solely for that purpose. The rationale for using omeprazole on a long-term basis is to prevent further acid damage to the lower esophagus and thereby limit esophagitis (inflammation of the esophagus) and control symptoms.

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My 15-year old son was diagnosed with Barrett's recently. He is taking 20 mg. of Prilosec two times a day. As he also has an acne problem, his dermatologist wants to treat him with Accutane since all other treatments and medications have failed.

Neither the gastroenterologist or the dermatologist had advised me about whether there are any problems in taking Accutane with his condition. A recent PH probe test showed Prilosec controlling the acid for 23 out of 24 hours. Are there any problems with his taking Accutane and should we watch for any specific symptoms? Any information you have would be appreciated. Arty

Dear Arty,

Accutane (isotretinoin) remains the most effective anti-acne therapy available. Since it was approved for the treatment of severe acne in the early 1980s, more that 7 million patients have received this medication.

The most common side effects of Accutane are dryness of the mouth, nose and eyes. It also commonly produces some redness of the facial skin with increased sensitivity to ultraviolet light.

About 15% of the patients taking Accutane complain of some muscle or joint pain, usually relieved with over-the-counter analgesics like Tylenol.

Because in some rare cases, patients taking Accutane developed abnormal liver blood tests and high cholesterol, most physicians routinely check these blood tests before starting treatment.

Accutane has also been safely used in many chronic diseases such as inflammatory bowel disease (ulcerative colitis and Crohn's disease), epilepsy, diabetes, multiple sclerosis, renal insufficiency and heart or kidney transplant patients.

Using a computerized medical literature database, we could not find any references to Accutane treatment in Barrett's Disease or interactions between Accutane and Prilosec.

Despite the lack of specific information about the use of Accutane in patients with Barrett's esophagus taking Prilosec, it is probably safest to remain under the supervision of your Dermatologist.

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I'm 40 years old and have had reflux for the last five years. I have been taking Prilosec for three of those years. When I went for an endoscopy three months ago, they found out I had Barrett's Esophagus with pre-cancer cells at that point.

My doctor said I should undergo surgery to have my whole esophagus removed and this scares me. So I went for a second opinion, and that doctor said there are other steps to take before surgery, such as laser treatment, freezing those cells or just a higher dose of Prilosec (e.g., 80 mg. per day) and just keep having endoscopies every three months.

Is 80 mg. of Prilosec too much and is three years too long to be on this medication? Are there any new options for me? Karl

Dear Karl,

The next step in your care depends on the degree of premalignant change. If you have low grade dysplasia, then higher doses of Prilosec or laser therapy is worth a try. If you have high grade dysplasia, you may want to consider surgery. Some surgeons are reporting an operation that removes the mucosa (inner lining) of the esophagus without removing the whole organ. You may want to ask you physician about this option, if your dysplasia is moderate or high grade.

Prilosec at 80 mg. per day is a high dose but should not present a problem in the short term. There is no danger in being on Prilosec for three years.

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My husband has had Barrett's for eight years and has an endoscopy every two years to assess malignancy. No malignancy has been evident to date. He has watched his diet and alcohol intake and has been on a prescription of 40 mg. of Pepcid two times daily for the eight years. This has been quite successful in controlling the symptoms.

His internist recently prescribed Prilosec and said if it was successful, he might take him off the Pepcid. I understand that Pepcid is an acid blocker and Prilosec is a neutralizer.

My husband would like to discontinue the Pepcid as we heard recently that long term use could affect testosterone levels and my husband has experienced evidence of that. What is your opinion regarding this change? Jan

Dear Jan,

The cause of Barrett's Esophagus is unclear, but current theory attributes the mucosal change to chronic exposure to gastric acid. The treatment of Barrett's esophagus, therefore, is directed towards suppression of gastric acid secretion.

Gastric acid secretion suppressants include proton pump inhibitors such as Prilosec and Prevacid, and H2 receptor inhibitors such as Pepcid, Zantac, Axid and Tagamet.

Prilosec and Prevacid are more potent suppressors of acid production than the H2 receptor inhibitors. Therefore, Prilosec and Prevacid would be the treatment of choice in reducing gastric acid secretion.

However, higher than usual dose of Pepcid (40 mg bid) as your husband has been receiving, may also achieve the same gastric acid suppression effect.

Currently, there is no published data or literature to indicate that long term use of Pepcid would affect male testosterone level or its biological function. If your husband has experienced sexual dysfunction, we recommend that he see his internist or endocrinologist regarding this issue.

Why do patients with Barrett's esophagus require repeated upper endoscopy? Endoscopic surveillance is necessary because Barrett's esophagus can develop into a malignant neoplasm of the esophagus. Detection of early changes suggesting evolution into cancer will allow for treatment to be initiated.

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After an endoscopy, I have been told that I have "ectopic gastric mucosa," or cells in my upper esophagus that secrete acid-like stomach cells. I'm told that I was born with these cells, as opposed to having Barrett's Esophagus.

I was also told this condition is fairly common, but I cannot find any references on the Web to such a condition.

My discomfort responds to Prevacid, but not to Zantac. It also responds to Pepto-Bismol chewable tables, but not to the new Pepto-Bismol capsules, which all seems to agree with the idea that the source of irritation is in the upper esophagus. Can you tell me more about this condition or where to look for more information? Wayne

Dear Wayne,

Columnar mucosa in the upper esophagus is a benign condition present since birth. Unlike Barrett's esophagus, this condition is not associated with the subsequent development of esophageal cancer.

Usually, there are no symptoms associated with this condition. Therefore, I am surprised by your history of pains. Are your doctors certain that the ectopic mucosa is the cause of your symptoms?

With regard to therapy, we would recommend using the medications which you know are effective. Finally, we are unaware of any web sites that would provide additional information regarding this condition.

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I am a 51-year old female who has had Crohn's Disease since I was 20. I have been very fortunate in that I have not had a lot of problems since age 30.

Two years ago, I had terrible problems with my esophagus. The gastroenterologist ran an endoscopy on me as he was convinced I had Barrett's, but the lab reports said this was not the case.

I went back for a two-year check, but also informed him that for several months I've had problems with pain in my abdominal area. He still feels I have Barrett's, but we are waiting for reports to come back. The pain is still really bad in the abdomen, but different from earlier years of the onset of Crohn's.

Presently, my physician has me on 30 mg. of Prevacid two times a day and .125 mg. of Hyoscyamine two times a day. I am very confused.

Since Crohn's can go anywhere in the digestive tract, I worry about what is going on in my esophagus, and if it is perhaps spreading to the small bowel. Most of the pain is centered near the navel, but is all over the intestinal area and even my stomach gets sore.

Adding to my worry is the fact that two years ago, my doctor informed me that biopsies from my colonoscopy showed I have pre-cancer cells present.

Could all these things be related? I have ignored pain for many years and just accepted it, but now the pain is too much to ignore. I am also so tired out that I just drag in everything I do. I really do appreciate any information you can give me. Carole

Dear Carole,

You are correct that Crohn's Disease can involve the entire GI tract from mouth to anus. Sometimes, physicians can have difficulty confirming active disease and therefore there is a delay in starting treatment.

Your e-mail raises several interesting issues. Barrett's esophagus and Crohn's Disease can both involve the esophagus although there is no compelling evidence that one condition predisposes to the other.

Biopsies of the esophagus can determine conclusively whether you have Barrett's esophagus. It can be more difficult to distinguish between Crohn's involvement of the esophagus and reflux esophagitis. An empiric trial with anti-reflux treatment including medication (Proton pump inhibitors e.g Prilosec and prokinetic agents e.g. Cisapride) is indicated.

You do not state if you had small intestine and/or colonic Crohn's Disease or whether you have required surgical intervention. Your complaints of diffuse abdominal pain and fatigue may represent a flare of your Crohn's disease, although other conditions must be considered. At this juncture it would be appropriate to have barium studies of your small intestine. Finally, the colonic precancer cells may be related to the Crohn's Disease.

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My mother was diagnosed with Barrett's Disease about a year ago. She also has Alzheimer's and I believe she is in stage 2.

She is scheduled for diagnostic endoscopies once a year to check for esophageal cancer. The endocrinologist she was seeing left and she is scheduled for her next endoscopy in a week, but her new endocrinologist told us he doesn't want to perform the procedure if we won't allow him to do surgery if he finds cancer. He really didn't give us an explanation as to what surgery would involve and what the impact on her life would be.

I've read some of the your responses in the Forum and see that there are alternatives to surgery. It seems to depend on the situation as to what the best treatment is. I was particularly intrigued by laser surgery and wondered how effective that has proven to be and what the survival rates tend to be as opposed to conventional surgery if the cancer is caught early.

Unfortunately, in my mother's case symptoms are hard to pin down with her Alzheimer's, although she frequently complains of chest pains. That is how they discovered the Barrett's. She is also seeing a cardiologist, who thinks she may have had a heart attack in the past year. She's taking a number of medications between the Alzheimer's, Barrett's disease and possible heart trouble. My main concern is the new endocrinologist's attitude. I'd appreciate any comments or suggestions you may have. Cindy

Dear Cindy,

Thank you for your questions regarding Barrett's esophagus. Screening endoscopy is done to identify premalignant changes in the esophageal mucosa, that is to identify abnormal cells before a cancer develops. When premalignant abnormalities are seen, the physician will suggest that the abnormality be removed. This approach is based on the clinical observation that once esophageal cancer develops, death usually occurs within one to two years.

Surgical resection has been the conventional treatment for the premalignant lesions of Barrett's esophagus, assuming that the patient is a good surgical candidate. However, there are other options now. Specifically, the use of PDT therapy with laser has been shown to eliminate the premalignant condition.

I do not know your mother's age or any information regarding her general medical condition, except for the Alzheimer's disease. Hopefully, your mother will not develop any premalignant changes. If she does develop abnormalities, endoscopic laser therapy would be valuable, although several treatments may be necessary.

If you believe that you do not want to do any therapy (surgery or laser) should premalignant conditions be identified, then you should consider discontinuing the annual screening studies because they do not add any value to your mother's care.

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My husband has recently been diagnosed with Barrett's Esophagus, but we have not had our follow up visit as we are waiting on results of biopsies and our doctor is out of town. He did say that the Barrett's has been there for some time and the examination sheet shows "severe reflux, induced lining change and imitation (Barrett's epithelium)."

I have thought for some time now that he may have cancer as he has been sick on and off for quite a while. He vomits several times a week, has constant pain, mostly on the right abdominal side and has felt at times that he is choking or cannot get enough air, mostly at night after going to bed.

We have waited four weeks and are finally seeing the doctor this week. One minute I think he's very sick and the next I'm not really sure. He has not been able to work because of his increased symptoms. What should I be looking for? What should we ask the doctor? Thank you. Bonnie

Dear Bonnie,

The majority of patients with Barrett's esophagus do not develop esophageal cancer (of the adenocarcinoma type) but the risk of developing esophageal cancer is much higher in patients with Barrett's when compared to the general population.

Therefore, the current recommendation is to perform surveillance endoscopy approximately every one to two years. The purpose of the surveillance endoscopies is to look for subtle changes in the cells of the esophageal lining which indicate malignant transformation. These changes are called dysplasia. Dysplasia can be classified as low grade or high grade. High grade dysplasia usually requires further management. Low grade dysplasia may signify more frequent surveillance.

Your husband's symptoms of vomiting, right sided abdominal pain and a choking sensation after going to bed are suggestive, but not necessarily diagnostic, for gastroesophageal reflux.

Barrett's esophagus is a consequence of prolonged damage to the lower esophageal lining from acid produced in the stomach and refluxed back into the esophagus. Barrett's esophagus may also be accompanied by inflammation in the lower esophagus called esophagitis. Many treatments including lifestyle modifications and medications are available to treat gastroesophageal reflux and its complications. Your doctor can help you with a medical regimen that is right for you. You should also ask your doctor if he feels that surveillance endoscopy is warranted, whether or not dysplasia is present and if so is it low grade, high grade or indefinite for dysplasia.

It is often difficult to predict whether a person has cancer based solely on symptoms. Nevertheless, symptoms that you should not ignore include: severe vomiting and abdominal pain, dysphagia (difficulty swallowing), weight loss and bleeding (both vomiting blood, rectal bleeding or black stools).

Good luck to you and we hope this information is helpful.

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I have Barrett's esophagus and have been told to stay away from fatty and acidic foods. I am looking for a list of foods that are considered acidic. I have been told about citrus and tomatoes, but wondered about others. I am 41 years old, 6'1" tall and 165 pounds. I am very active and run 18 to 20 miles per week. My GERD is controlled with medication, so my biggest concern now is proper diet. Any help you can provide me is greatly appreciated. Dennis

Dear Dennis,

Certain foods can increase reflux by causing relaxation of the lower esophageal sphincter (LES). Caffeinated beverages, carbonated drinks, cigarettes, alcohol, fatty foods, mints and chocolate can all aggravate LES incompetence and reflux symptoms. Moreover, foods that stay in the stomach longer (such as fried, or fatty foods) tend to increase reflux symptoms and the amount of acid that enters the esophagus.

It is unclear whether "acidic" food cause increased acid production in the stomach. Although acidic food may worsen symptoms by irritating the already injured lining of the esophagus, they probably do not alter the severity or course of reflux disease and Barrett's esophagus.

However, be pragmatic. Do no eat foods that cause you discomfort. Once the active inflammation of the esophagus has healed, you may find that you can tolerate certain "acidic" foods again.

If you refrain from taking caffeinated beverages, carbonated drinks, cigarettes, alcohol, fatty foods, mints and chocolate, your symptoms should improve considerably and you will facilitate healing of esophageal inflammation.

In addition, since reflux is more likely to occur when lying flat, raising the head of the bed prevents stomach fluid from flowing back into the esophagus. Generally, raising the bed four to six inches is recommended. Books or blocks under the legs of the bed or a wedge under the mattress can be used.

Since stomachs full of food and acid are more likely to reflux, avoiding bedtime snacks and eating meals at least three to four hours before lying down can help reduce reflux. The above measures will probably be more advantageous than abstaining from "acidic" food.

Lastly, persons with severe reflux disease and persons with Barrett's esophagus should take medications to suppress the acid production by the stomach, in addition to the measures outlined above.

You are doing all the right things to take good care of your body. Keep up the good work.

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I have been diagnosed with Barrett's esophagus and as having a hiatal hernia. I pretty much have the acid reflux problem under control due to lifestyle changes, but I am wondering if the cell damage done to my esophagus is reversible. I know this is considered a premalignant condition and would like to know that one day this worry will be gone. Thank you. Candace

Dear Candace,

We assume that your Barrett's esophagus was diagnosed by a test called an endoscopy with biopsy of the esophageal mucosa. Barrett's esophagus is the result of acid reflux from the stomach into the esophagus, resulting in damage to the lining with replacement of the normal lining by an abnormal cell type. You are correct that this is a premalignant condition. Fortunately, few people develop cancer.

It is controversial whether Barrett's esophagus can revert to a normal lining (mucosa). Medical or surgical therapy, however, can heal the esophagitis or acute inflammation.

Currently patients with Barrett's esophagus are screened by endoscopy and biopsy every two years to verify that there has been no evolution towards malignant change of the mucosa. Therefore, we would advise you to maintain in contact with your physician.

You should also be aware that there are new endoscopic treatments to treat these early premalignant changes. A technique called photodynamic therapy is being investigated to determine its efficiency in the destruction of this abnormal mucosa.

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