This document discusses the management of Barrett's esophagus, which is the development of intestinal metaplasia in the esophagus. It presents the stages of progression from non-dysplastic Barrett's to low-grade dysplasia to high-grade dysplasia and eventually cancer. It reviews the risks of progression and recommends surveillance strategies. It also discusses endoscopic treatment options like endoscopic mucosal resection and radiofrequency ablation to remove dysplastic tissue, with the goal of complete eradication of Barrett's. Acid suppression with proton pump inhibitors is an essential part of co-therapy.
Barrett's esophagus is a condition in which the tissue lining the esophagus—the muscular tube that connects the mouth to the stomach—is replaced by tissue that is similar to the lining of the intestine. This process is called intestinal metaplasia.
No signs or symptoms are associated with Barrett's esophagus, but it is commonly found in people with gastroesophageal reflux disease (GERD). A small number of people with Barrett's esophagus develop a rare but often deadly type of cancer of the esophagus.
Barrett's esophagus affects about 1 percent1 of adults in the United States. The average age at diagnosis is 50, but determining when the problem started is usually difficult. Men develop Barrett's esophagus twice as often as women, and Caucasian men are affected more frequently than men of other races. Barrett's esophagus is uncommon in children.
The EsophagusThe esophagus carries food and liquids from the mouth to the stomach. The stomach slowly pumps the food and liquids into the intestine, which then absorbs needed nutrients. This process is automatic and people are usually not aware of it. People sometimes feel their esophagus when they swallow something too large, try to eat too quickly, or drink very hot or cold liquids.
Digestive tract.
The muscular layers of the esophagus are normally pinched together at both the upper and lower ends by muscles called sphincters. When a person swallows, the sphincters relax to allow food or drink to pass from the mouth into the stomach. The muscles then close rapidly to prevent the food or drink from leaking out of the stomach back into the esophagus and mouth.
NIDDK
Barrett's esophagus is a condition in which the tissue lining the esophagus—the muscular tube that connects the mouth to the stomach—is replaced by tissue that is similar to the lining of the intestine. This process is called intestinal metaplasia.
No signs or symptoms are associated with Barrett's esophagus, but it is commonly found in people with gastroesophageal reflux disease (GERD). A small number of people with Barrett's esophagus develop a rare but often deadly type of cancer of the esophagus.
Barrett's esophagus affects about 1 percent1 of adults in the United States. The average age at diagnosis is 50, but determining when the problem started is usually difficult. Men develop Barrett's esophagus twice as often as women, and Caucasian men are affected more frequently than men of other races. Barrett's esophagus is uncommon in children.
The EsophagusThe esophagus carries food and liquids from the mouth to the stomach. The stomach slowly pumps the food and liquids into the intestine, which then absorbs needed nutrients. This process is automatic and people are usually not aware of it. People sometimes feel their esophagus when they swallow something too large, try to eat too quickly, or drink very hot or cold liquids.
Digestive tract.
The muscular layers of the esophagus are normally pinched together at both the upper and lower ends by muscles called sphincters. When a person swallows, the sphincters relax to allow food or drink to pass from the mouth into the stomach. The muscles then close rapidly to prevent the food or drink from leaking out of the stomach back into the esophagus and mouth.
NIDDK
reviewed the literature ;Multidisciplinary management of gastric cancer
Yixing Jianga and Jaffer A. Ajani
; pictures taken from Sabiston textbook of surgery.
CARCINOMA ESOPHAGUS - DR ZAHID IQBAL MIR
Dr. Zahid Iqbal Mir, MBBS MS (General Surgery), DNB (General Surgery) has done his MBBS and masters in General Surgery from the prestigious Govt Medical College Jammu and DNB in General Surgery from NBEMS New Delhi. He is a passionate surgeon, earlier practising at Government Medical College, Jammu as Registrar in Department of General Surgery. Nowadays working as Senior Resident in Department of General Surgery, Government Medical College & Hospital, Sector 32, Chandigarh and a rising name in field of surgery.
He is an enthusiastic, enigmatic and dedicated teacher as well. He is not just a resolute learner, but also an awe inspiring guiding light for his juniors, which makes him the most loveable and respected senior.
Currently he is running “LOVE FOR SCALPEL” for PGMEE aspirants on most of the social platforms, which is gaining immense popularity among residents, medical graduates and undergraduates.
CARCINOMA ESOPHAGUS - DR ZAHID IQBAL MIR
Dr. Zahid Iqbal Mir, MBBS MS (General Surgery), DNB (General Surgery) has done his MBBS and masters in General Surgery from the prestigious Govt Medical College Jammu and DNB in General Surgery from NBEMS New Delhi. He is a passionate surgeon, earlier practising at Government Medical College, Jammu as Registrar in Department of General Surgery. Nowadays working as Senior Resident in Department of General Surgery, Government Medical College & Hospital, Sector 32, Chandigarh and a rising name in field of surgery.
He is an enthusiastic, enigmatic and dedicated teacher as well. He is not just a resolute learner, but also an awe inspiring guiding light for his juniors, which makes him the most loveable and respected senior.
Currently he is running “LOVE FOR SCALPEL” for PGMEE aspirants on most of the social platforms, which is gaining immense popularity among residents, medical graduates and undergraduates.
reviewed the literature ;Multidisciplinary management of gastric cancer
Yixing Jianga and Jaffer A. Ajani
; pictures taken from Sabiston textbook of surgery.
CARCINOMA ESOPHAGUS - DR ZAHID IQBAL MIR
Dr. Zahid Iqbal Mir, MBBS MS (General Surgery), DNB (General Surgery) has done his MBBS and masters in General Surgery from the prestigious Govt Medical College Jammu and DNB in General Surgery from NBEMS New Delhi. He is a passionate surgeon, earlier practising at Government Medical College, Jammu as Registrar in Department of General Surgery. Nowadays working as Senior Resident in Department of General Surgery, Government Medical College & Hospital, Sector 32, Chandigarh and a rising name in field of surgery.
He is an enthusiastic, enigmatic and dedicated teacher as well. He is not just a resolute learner, but also an awe inspiring guiding light for his juniors, which makes him the most loveable and respected senior.
Currently he is running “LOVE FOR SCALPEL” for PGMEE aspirants on most of the social platforms, which is gaining immense popularity among residents, medical graduates and undergraduates.
CARCINOMA ESOPHAGUS - DR ZAHID IQBAL MIR
Dr. Zahid Iqbal Mir, MBBS MS (General Surgery), DNB (General Surgery) has done his MBBS and masters in General Surgery from the prestigious Govt Medical College Jammu and DNB in General Surgery from NBEMS New Delhi. He is a passionate surgeon, earlier practising at Government Medical College, Jammu as Registrar in Department of General Surgery. Nowadays working as Senior Resident in Department of General Surgery, Government Medical College & Hospital, Sector 32, Chandigarh and a rising name in field of surgery.
He is an enthusiastic, enigmatic and dedicated teacher as well. He is not just a resolute learner, but also an awe inspiring guiding light for his juniors, which makes him the most loveable and respected senior.
Currently he is running “LOVE FOR SCALPEL” for PGMEE aspirants on most of the social platforms, which is gaining immense popularity among residents, medical graduates and undergraduates.
2. BE: Definition
§
Red (columnar) mucosa in the
esophagus; variable length
–
Described by the Prague classification
• C: length of the circumferential section
• M: length of the any circumferential section plus
the length of any tongues
§
Biopsies demonstrate goblet cells
–
Goblet cells are not seen in the normal
stomach but are seen in the intestine
• Goblet cells define “intestinal metaplasia”
3. BE: Significance
§
Risk of esophageal adenocarcinoma
(EAC)
§
EAC associated with:
–
BE
–
White males
–
Chronic GERD
–
Obesity
–
Family history of EAC
4.
5.
6.
7. PROGRESSION OF BARRETT’S
TO ADENOCARCINOMA
§
simple Barrett’s (no dysplasia)
§
Barrett’s with low grade dysplasia
§
Barrett’s with high grade dysplasia
§
adenocarcinoma
8.
9.
10.
11. Is it Really Dysplastic?
Home Institution Diagnosis
12. Outline
§
What are the risks of progression of BE
stages to cancer?
§
What are the management options for
LGD, HGD and early stage cancer?
§
Can we define a management algorithm
for endoscopic intervention in BE?
13. Surveillance strategies
Interval
Barrett’s no dysplasia in 1 year, then q 3y
LGD in 3 mo, then 1 year
HGD intervention best
(q 3 mo X 4, then qy)
Wang et al AJG 2008;103:788-97
15. Interventions in Barrett’s
§
Nodular disease – must be removed by
EMR
–
Provides effective therapy for nodules with
HGD or IM CA
–
Provides more accurate staging than EUS
§
Flat disease
–
Best treatment: RFA (BARRX)
–
Alternatives:
• Cryotherapy
• Photodynamic therapy
16. Risk of progression to EAC
determines appropriateness of
intervention
per year intervene ?
§
Barrett’s 0.1-0.2% controversial
§
LGD 1.7 -3.7% optional
§
HGD 5-8% yes
17. How Benign is Low-Grade Dysplasia?
§
147 subjects with a diagnosis of LGD made in a
community practice in the Netherlands
§
Path reviewed by 2 expert pathologists
–
Disagreements resolved by consensus
§
85% of cases were down-graded
§
In the 15% who were not, the incidence rate of
HGD or EAC was 13.4%/pt-yr (mean f/u: 51
months)
Curvers WL et al. Am J Gastroenterol 2010, pub pend.
18. Progression to Cancer in HGD
0% 20% 40% 60%
Reid et al Am J gastro 2000;95:1669-76
Schnell et al Gastro 2001;120:1607-19
Buttar et al Gastro 2001;120:1630-9
19. What is the Risk of Death with
Esophagectomy?
Birkmeyer et al, N Engl J Med 2002;346:1128-37
20. High frequency probe
(20MHz) EUS in HGD and IMC
– 9 patients
§
Correct – 45%
§
Understaged – 33%
§
Overstaged – 22%
–
Waxman et al AJG 2006;101:1773
21. Clinical response to EMR
staging
EMR stage Risk of lymph node met
§
T1a (mucosa only) 0-7%
§
T1b (submucosa) ~ 15-20%
31. Why not use EMR for entire
long segments of Barrett’s?
§
Distortion of anatomy for subsequent RFA
§
Stricture formation
–
Limit the extent of resection
§
Bleeding
–
Clip placement
§
Perforation
–
Removable stent placement
35. Is EMR adequate therapy in
Barrett’s?
§
Yes if it fully removes the Barrett’s
§
No if there is residual Barrett’s – especially
after there resection of IM EAC
–
11% rate of metachronous cancer if EMR
alone
• Ell et al GIE;2007:65:3-10
–
12% rate of metachronous cancer if EMR
alone
• Prasad et al Gastroenterology 2009;137:815-23
36. General Rule:
§
If ablation is undertaken should go for full
eradication
§
Basic strategy
–
Nodular disease by EMR
–
Flat disease by RFA
37. PDT for HGD
§
RCT of 208 patients
§
2:1 PDT plus PPI vs PPI alone
§
Reduced risk of cancer by 50% (did not
eliminate it – 15% vs 29%)
§
HGD eliminated in 78% vs 39%
–
Overholt GIE;2005;62:488-98
47. Randomized, Sham-Controlled Trial of Radio-
frequency Ablation of Dysplasia in Barrett’s
% with No Dysplasia at
12 months (ITT)
10
8
6
4
2
0
High-Grade Low-Grade
Dysplasia Dysplasia
Shaheen. N Engl J Med 2009;360:2277-88
48. Randomized, Sham-Controlled Trial of Radio-
frequency Ablation of Dysplasia in Barrett’s
at 12 Months (ITT)
10
% with No IM
8
6
4
2
0
Halo 360 Sham
Ablation Ablation
Shaheen. N Engl J Med 2009;360:2277-88
49. Randomized, Sham-Controlled Trial of Radio-
frequency Ablation of Dysplasia in Barrett’s
% with Progression
10
8
6
4
2
0
Progression of Progression
Neoplasia to Cancer
Shaheen. N Engl J Med 2009;360:2277-88
50. If RFA can’t be applied or is
unsuccessful?
§
Cryotherapy
§
APC
§
MPC
51. Cryotherapy in HGD: An Initial Report
•
98 subjects w/ HGD
§
treated at 10
institutions
§
- 61 completed Rx, 27
§
ongoing
•
281 total procedures
§
- 4.0/pt
•
No perfs, no buried
§
glands, no bleeds or
§
chest pain requiring
§
hospitalization
•
One progression to CA
52. Should non-dyplastic
Barrett’s be ablated?
§
AIM Trial – rates of CR – IM
–
2.5 y : 98% with sustained CR
–
5 y: 92% with sustained CR
53. Should non-dysplastic
Barrett’s be ablated? Cost
issues
§
Das; Endoscopy 2009;41:750-8
–
RFA > cost by more QALYs
–
$48,626/QALY
§
Inadomi; Gastroenterology
2010;136:2101-14
–
RFA more CE if rate of CR-IM 40% and
surveillance continued
–
RFA more CE for LGD if CR-D achieved in 28%
and CR-IM in 0% and surveillance continued
54. Other considerations:
(tailored therapy)
§
Age
§
Comorbidities
§
Patient preferences
55. Ablation is 2 part therapy
§
Acid suppression – §
Destruction of the
patient must be on Barrett’s mucosa
double dose PPIs
and take them
properly and
consistently
56. Related issues -
Chemoprevention
§
NSAIDs
–
OR for cancer - case control studies
0.57(0.47-0.71)
–
RCT of celecoxib: no benefit
§
PPIs
–
2 retrospective cohort studies suggest
benefit
• Large scale trials with aspirin and PPIs are
underway
57. Conclusions
§
EMR for nodular disease
–
Fulfills dual role of treatment and staging
§
RFA for flat disease
§
PPI co-therapy essential
§
Ablate all Barrett’s if possible
§
Widely accepted to treat HGD and LGD
§
Increasing acceptance of treating ND-BE
§
Therapy also tailored to patient age, comorbidities and
preferences