The Patient Support Network of Barrett's Oesophagus Foundation
Managing the Complications
Barrett's ulcers
These are due to a breakdown in the gullet lining. They may cause symptoms such as:
- Chest pain
- Pain on swallowing
- Unusual stools: Passing black, "tarry" or bloody stool
- Bleeding: Vomiting red blood or blood that looks like "coffee grounds"
- Symptoms of anaemia (low blood count) such as lethargy
Barrett's ulcers are diagnosed by endoscopy (camera examination of the gullet and stomach). Treatment may include increasing your acid lowering medications or occasionally surgery to prevent reflux of acid. If you are anaemic this may be treated with iron tablets or a blood transfusion.
Stricture
This is a narrowing in the gullet that may cause:
- Dysphagia or difficulty in swallowing
- An unexpected drop in weight
If you develop the above symptoms you should consult your doctor.
A stricture may be diagnosed by performing an endoscopy or a barium swallow (X-ray examination of the gullet and stomach taken after drinking dense liquid called barium which shows up on the X-ray).
Strictures are treated with dilatation (stretching the narrowed gullet). This involves an endoscopy, usually under X-ray control, before passing a tube or balloon to stretch the gullet. This is usually undertaken as a day case procedure. It is also necessary to reduce the acid reflux into the oesophagus to prevent reformation of the stricture. This is achieved by increasing the dose of acid lowering medications or occasionally by surgery to correct the reflux.
Precancerous change (Dysplasia)
In a very small proportion of patients (less than one percent per year) Barrett's oesophagus can gradually lead to cancer of the gullet or upper stomach. This may take many years to develop and is usually preceded by a further cell change within the Barrett's lining to abnormal appearing cells (dysplasia). These abnormal appearing cells are currently best diagnosed by examining small tissue samples under the microscope.
Biopsies are analysed under the microscope by a pathologist. The images below show typical appearances. The first image shows Barrett's mucosa, the second shows High grade dysplasia
The abnormal cells are thought to progress through a low grade state (low-grade dysplasia) to high grade dysplasia (very abnormal appearing cells) before becoming cancerous . It can, however, take up to 10 years for dysplasia to develop into cancer, although it's not possible to predict in any individual patient how long it will take for this change to occur. In some people, cancer may have already started developing within the area of high-grade dysplasia at the time it is diagnosed.
This gradual progression explains why an increasing number of hospitals perform endoscopies at regular intervals (called surveillance). The aim of these programmes is to detect any dysplasia before it progresses to cancer.
These changes DO NOT necessarily progress to cancer and repeating the endoscopy and tissue sampling may show Barrett's lining only WITHOUT any abnormal appearing cells (dysplasia).
What happens if precancerous change (dysplasia) is found)?
If the pre-cancerous cell change (dysplasia) is detected within the Barrett's lining, the endoscopy and tissue sampling are repeated more frequently- generally 6 monthly for low grade dysplasia or 3 monthly if high grade dysplasia is found, to monitor these changes.
If repeating the endoscopy and tissue sampling shows high-grade dysplasia and particularly if found in several of the biopsies, treatment is recommended. High-grade dysplasia is strongly associated with cancer of the gullet and treatment of this early stage can potentially cure the risk of cancer.
Assessment may include:
- CT scan - this is a special X-ray to examine the chest and liver to assess whether there is any cancer present
- Endoscopic ultrasound - a special ultrasound scan that involves a test similar to the endoscopy (camera examination) but using an ultrasound probe
Treatment
The surgical treatment of individuals with high-grade dysplasia is controversial. Many experts believe that patients should undergo an operation to remove the gullet, called an oesophagectomy, as a curative measure. Some believe that surveillance through endoscopies at 3 to 6 month intervals is sufficient and that an operation should be reserved for patients who have developed cancer. Unfortunately, an oesophagectomy is very major surgery and usually involves opening both the stomach and the chest. It takes some months for people to return to full health after this. Surgery is therefore not generally recommended for patients with declining health or for those who are too weak to withstand a major procedure. Therefore, alternative treatments are being investigated.
These alternative treatments involve removal (ablation) of the abnormal Barrett's lining during an endoscopy. Procedures include:
- Photodynamic therapy: A drug is given to make the Barrett's cells sensitive to light. A light is then inserted into the oesophagus. Tissues that the light touches are burned off
- Multipolar polar electrocautery: An electric wire is inserted into the oesophagus and burns away dysplasia
- Laser therapy: Barrett's cells are burned with a hot beam of light (laser) inserted in the oesophagus. This is effective but difficult to apply evenly
- Argon plasma coagulation: A jet of argon gas is released into the gullet along with an electric current that burns away dysplasia
- Endoscopic Mucosal Resection (EMR): If only a small area of the Barrett's lining is affected by dysplasia this may be removed by a suction and snare procedure which is performed at an endoscopy
These procedures are usually combined with strong doses of proton pump inhibitors (acid lowering tablets) to try to ensure that the abnormal lining does not re-grow.
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