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    1378903 634690510741915000 1378903 634690510741915000 Presentation Transcript

    • BY-Aman Kailash Setiya
    • What is Barrett’s Esophagus?  The esophagus gets a tissue lining similar to that of the intestines  The muscle becomes rougher  The cells that are normally found in the intestine replace the normal esophagus cells
    • Estimated prevalence of Barrett’s esophagus  6-12% of patients who undergo EGD for GERD. Short-segment BE: 6-12% Long-segment BE: 1-5%  1-2% of unselected patients who undergo EGD  Most cases go undetected in the general population [Autopsy data]. Perhaps 5% of patients with Barret esophagus are currently being diagnosed.
    • Symptoms of Barretts esophagus  There are no specific symptoms, they vary per person Some signs it is likely include:  Constant acid reflux  Burning sensations near chest bone  Pain in throat and chest when eating
    •  frequent and longstanding heartburn  trouble swallowing (dysphagia)  vomiting blood (hematemesis)  pain under the breastbone where the esophagus meets the stomach  unintentional weight loss because eating is painful
    • Risk factors for development of Barrett’s esophagus  Male gender 3 times > female gender  White race >> Blacks & Asians  Abdominal adiposity (obesity)  Genetic factors suspected in some patients/families  Chronic reflux symptoms for > 5-10 years  Age >40-50 years; mean age at diagnosis = 55 yrs
    • Mechanism  Barrett esophagus occurs due to chronic inflammation. The principal cause of the chronic inflammation is gastroesophageal reflux disease, GERD . In this disease, acidic stomach, bile, small intestine and pancreatic contents cause damage to the cells of the lower esophagus
    • Damage to the squamous esophageal mucosa Injury heals through a metaplastic process (columnar cells replace squamous cells) Pathogenesis of Barrett’s Esophagus GERD Injury heals with restoration of squamous mucosa
    • Long-segment versus short-segment Barrett’s esophagus  Long-segment BE (LSBE): >3-cm segment of distal esophagus (columnar mucosa with intestinal metaplasia)  Short-segment BE (SSBE): <3-cm segment (usually tongues or islands of columnar mucosa with intestinal metaplasia)  Patients with LSBE tend to have greater esophageal acid exposure than SSBE, as well as lower LES pressures and more esophageal dysmotility.  LSBE (classic BE) is much better studied.  We are currently managing LSBE and SSBE similarly.  However, questions remain:  Does SSBE have the same pathogenesis?  Does SSBE have a lower risk of cancer?  Does SSBE progress to LSBE?  Does the length of BE correlate with cancer risk?
    • Long segement type Short segement type
    • Physiology of Barrett’s Esophagus  When food becomes backed up, the juices of the stomach go back up the esophagus.  This is also known as severe acid reflux.  When having a repeated injury to the Esophagus , acidic fluid changes the types of cells lining it from squamous to columnar .(METAPLASIA)  Fluid may contain bile acids.
    • Development of Neoplasia in Barrett’s Esophagus 1 2Gastric acid reflux 2 1Duodenal bile reflux Pro-carcinogenic primary and secondary bile salts 3 pH dependent,bile salt induced chronic esophageal injury 4 Chronic esophageal inflammation and PGE2release 5 Neoplasia in Barrett’s esophagus
    • Development of esophageal adenocarcinoma from Barrett’s esophagus  Compelling evidence exists for a dysplasia-carcinoma sequence in BE.  Specialized columnar epithelium progresses in some patients → low-grade dysplasia → high-grade dysplasia → adenocarcinoma.  Not every patient with low-grade dysplasia progresses, and low-grade dysplasia can even spontaneously revert back to no dysplasia.  Time course for development of cancer highly variable.  Most patients never progress to dysplasia. Less than 5% of Barrett’s patients will develop cancer.
    • Why do we care about Barrett’s esophagus?  Patients with BE have an increased risk of developing esophageal adenocarcinoma.  Over the past 30 years, the incidence of squamous cell cancer of the esophagus has stayed constant, while the incidence of adenocarcinoma has increased 6-fold! This is an increase that exceeds that of any other cancer.  Today, adenocarcinoma accounts for more than half of esophageal cancers.  Patients with BE have about a 30-40 fold increased risk of adenocarcinoma of esophagus.  Risk of a BE patient developing cancer is estimated to be about 1 per 200 patient-years follow-up.  Despite all this, most patients with BE do not develop esophageal cancer. [Less than 5%]
    • Diagnosis  GERD is a precursor to the diagnosis of Barrett’s Esophagus.  The tissue lining of the esophagus has changed.  Endoscopy (a long thin tube that examines the lining of the esophagus and stomach) confirms whether or not cells are abnormal.
    • 1. Locate gastro- esophageal junction 3. Describe extent of metaplasia consistently 2. Recognize the squamocolumnar junction Three Essential Steps for Endoscopic Diagnosis and Description
    • Therapy of Barrett’s Esophagus Antisecretory therapy Surgery Ablation Chemoprevention
    • TREATMENT AND MANAGEMENT TACTICS  TREATMENT OF the mai cause that is GERD- Treatment should improve acid reflux symptoms, and may keep Barrett's esophagus from getting worse. Treatment may involve lifestyle changes and medications such as:  Antacids after meals and at bedtime  Histamine H2 receptor blockers(viz rantidine famotidine etc)  Proton pump inhibitors(pantoprazole,lansoprazole etc)
    • N.B.- Lifestyle changes, medications, and anti- reflux surgery may help with symptoms of GERD, but will not make Barrett's esophagus go away.
    • TREATMENT OF BARRETT'S ESOPHAGUS  Surgery or other procedures may be recommended if a biopsy shows cell changes that are very likely to lead to cancer. Such changes are called severe or high-grade dysplasia.
    •  Surgery  Removal of intestinal cells from esophagus and replacement of esophageal cells  Removal of the esophagus
    • Recent advance in surgical method  Photodynamic therapy (PDT) uses a special laser device, called an esophageal balloon, along with a drug called Photofrin.  Other procedures use different types of high energy to destroy the precancerous tissue.  Surgery removes the abnormal lining.
    • Fun and Interesting Facts  Only about 1% of all Americans suffer from Barret’s Esophagus  10% to 15% of people with chronic GERD get Barrett’s Esophagus.  About 3.3 million adults over 50 years of age in the United States have Barrett’s Esophagus.  Men are more likely to develop Barrett’s Esophagus than women and the ratio is 2:1, and EUROPEAN males are more likely to have it than any other race.
    • ?QUESTIONS?