Makindo Medical Notes

Related Subjects: |Achalasia |Oesophageal Carcinoma |Diffuse Oesophageal spasm |Diffuse Oesophageal Perforation - Rupture |Gastro-Oesophageal Reflux |Barrett's oesophagus

🧪 Barrett's oesophagus is a premalignant condition where the normal squamous epithelium of the distal oesophagus is replaced by specialised intestinal-type columnar epithelium due to chronic acid exposure from GORD. ⚠️ This metaplastic change increases the lifetime risk of developing oesophageal adenocarcinoma.

📌 About

• Defined as endoscopically visible columnar epithelium extending ≥1 cm above the gastro-oesophageal junction (GOJ), confirmed histologically.
• Normal pale-grey squamous lining → replaced by salmon-pink columnar mucosa.
• Diagnosis requires both endoscopic evidence and biopsy confirmation.

🧬 Aetiology

• Chronic GORD → repeated acid/bile reflux damages squamous lining.
• Healing occurs with intestinal metaplasia (columnar epithelium with goblet cells).
• Risk factors: Male sex, >45 years, Caucasian ethnicity, central obesity, smoking, and chronic reflux symptoms.

🔥 Risk of Malignant Transformation

🔎 Investigations

• Endoscopy: Columnar epithelium appears salmon-pink vs normal pale-grey squamous mucosa.
• Seattle protocol biopsies: Quadrantic biopsies every 2 cm (or 1 cm if dysplasia suspected).
• Histology: Assess for goblet cells and grade dysplasia:
  • No dysplasia
  • Low-grade dysplasia
  • High-grade dysplasia
• Adjuncts: Chromoendoscopy (e.g. indigo carmine) to highlight dysplasia.

💊 Management

• Lifestyle & diet: Weight loss, avoid alcohol, caffeine, spicy foods, elevate head of bed, smoking cessation.
• Acid suppression: Long-term PPIs (high dose if symptoms persist). H2 antagonists are less effective.
• Endoscopic surveillance: Based on length and dysplasia grade (see NICE below).
• Endoscopic therapy:
  • Radiofrequency ablation (RFA) → first-line for dysplasia.
  • Endoscopic mucosal resection (EMR) → removes visible lesions.
  • Cryotherapy → alternative for ablation.
• Surgery: Oesophagectomy for high-grade dysplasia or intramucosal carcinoma where endoscopic therapy not suitable.

📏 Screening & Surveillance (NICE)

• Long-segment (≥3 cm): Endoscopy every 2–3 years.
• Short-segment (<3 cm) with intestinal metaplasia: Endoscopy every 3–5 years.
• No intestinal metaplasia confirmed: No surveillance after 2 negative endoscopies.
• Indefinite for dysplasia: Optimise acid suppression → repeat in 6 months.
• High-grade dysplasia → endoscopic eradication therapy preferred over surveillance alone.

📚 References

• BSG Guidelines on Diagnosis & Management of Barrett’s Oesophagus
• NICE CG106: Barrett’s Oesophagus and Oesophageal Cancer

Cases — Barrett’s Oesophagus

• Case 1 (Non-dysplastic): A 44-year-old man with long-standing reflux presents with heartburn despite PPI use. Endoscopy shows a 3 cm segment of salmon-coloured mucosa above the gastro-oesophageal junction. Biopsies confirm intestinal metaplasia without dysplasia.
  Management: Optimised high-dose PPI therapy, lifestyle advice (weight loss, alcohol/caffeine avoidance), and enrolment into endoscopic surveillance programme every 3–5 years. Outcome: Symptoms improve with medication. No progression on repeat endoscopy at 3 years.
• Case 2 (Low-grade dysplasia): A 61-year-old man with obesity and reflux symptoms undergoes endoscopy for persistent dyspepsia. A 4 cm Barrett’s segment is seen; histology shows low-grade dysplasia. Management: Referred for endoscopic radiofrequency ablation (RFA) after PPI optimisation. Close endoscopic surveillance arranged at 6–12 month intervals. Outcome: Successful eradication of dysplastic tissue with RFA. Remains under annual endoscopic surveillance.
• Case 3 (High-grade dysplasia/early cancer): A 72-year-old man presents with progressive dysphagia and weight loss. Endoscopy reveals a nodular Barrett’s segment; biopsies show high-grade dysplasia with intramucosal carcinoma. Management: Endoscopic mucosal resection (EMR) of the lesion, followed by RFA of residual Barrett’s segment. Multidisciplinary team (MDT) review confirms no invasive cancer. Outcome: Good symptom relief, no recurrence at 1-year follow-up. Enrolled in close surveillance programme.

Teaching Commentary 🧑‍⚕️

Barrett’s oesophagus is the replacement of normal squamous epithelium by intestinal-type columnar epithelium due to chronic reflux. It is a precancerous condition with risk of oesophageal adenocarcinoma. Management depends on histology: • Non-dysplastic → PPI + surveillance. • Low-grade dysplasia → endoscopic therapy (RFA) ± close monitoring. • High-grade dysplasia / intramucosal carcinoma → EMR + RFA or surgery if invasive. Lifestyle modification is essential in all cases. Long-term follow-up is required, as progression risk is ~0.1–1% per year depending on dysplasia grade.