Barrett’s esophagusThomas C. Caves, MD

Digestive Health Associates

August 8, 2016

Definition

• Metaplastic columnar epithelium

• replaces normal squamous epithelium (above the Z-line)

• presence of goblet cells

• Short versus long segment

• Prague Scoring system

Normal EGJ (Z-line)

Long segment Barrett’s esophagus

Short segment Barrett’s esophagus

Barrett’s “islands”

Histology

Normal Barrett’s esophagus

Goblet cells

Epidemiology

• 1% of general population

• 3.5 million patients in the US

• 5% without reflux symptoms

• 5-15% in patients with reflux

• 2:1 male predominance

Risk Factors

• GERD

• erosive esophagitis

• Genetics

• germline MSR1 mutations

• Obesity

• Age

• Gender/Race

Dysplasia

• Low grade or high grade

• Varies depending length of Barrett’s esophagus• Short segment 8%

• Long segment 24%

Degrees of dysplasia

Low grade High grade

Risk of Adenocarcinoma of the EGJ

• Varies with degree of dysplasia

• Non dysplastic 0.1-0.4% per year

• Low grade dysplasia 1.0% per year

• High grade dysplasia 6-10% per year

Adenocarcinoma of the EGJ

Esophageal cancer

Screening Surveillance

• Male

• Older

• Obese (abdominal)

• Caucasian

• GERD

• Hiatal hernia

• Repeat EGD 1 year after diagnosis then every 3-5 years

• Low grade dysplasia- 6 months (or treat)

• High grade dysplasia-treat

Treatment

• Acid suppression

• Weight loss

• Aspirin

• plus as statin?

• Ablation

Radiofrequency ablation

• Radiofrequency energy applied directly to Barrett’s tissue

• 360 degrees via balloon

• 90 degrees via probe attached to scope

Radiofrequency Ablation Indications

• High grade dysplasia

• Low grade dysplasia

• Non dysplastic Barrett’s• Not yet

Halo 360 (balloon) ablation

• https://www.youtube.com/watch?feature=player_de

tailpage&v=iu4kv90cOII

Halo 90 ablation

• https://www.youtube.com/watch?v=q6x8_pVvvAc

&feature=player_detailpage

Eradication Rates

• Complete

• 80-100%

• Dysplasia

• 90-100%

RFA complications

• Stricture

• Chest pain

• Bleeding

• Perforation

Other Treatments

• Photodynamic therapy

• Cryoablation

• Esophagectomy

• Endoscopic mucosal resection (raised lesions)

• Surveillance (low grade dysplasia)

What next (after RFA)?

• Surveillance endoscopy

• 3, 6, 12 months

• Acid suppression

• 20% recurrence rate

• Weight loss

• ?NSAID’s

Future of Barrett’s Esophagus

• Identification of at risk patients

• Sampling techniques

• Markers for progression to dysplasia/carcinoma

• RFA for all patients?

• Chemoprophylaxis