Specialist presentation 4 11-19

Barrett’s Esophagus & Esophageal Cancer
Rajesh Krishnamoorthi, MD
April 11, 2019

© 2017 Virginia Mason Medical Center
Outline
• What is GERD?
• What is Barrett’s esophagus?
• What is the relation between GERD
and Barrett’s esophagus?
• What is the relation between Barrett’s
esophagus and Esophageal cancer?
• Who should be screened for Barrett’s?
• If you have Barrett’s, what’s next?

What is GERD?
4
- First described in 1935
in JAMA medical journal
- Asher Winkelstein MD –
Mount Sinai, NY
- ‘Peptic Esophagitis’ 
Gastro Esophageal
Reflux Disease (GERD)

How common is GERD?
~ 60 million Americans have GERD
5
Prevalence
(%)
0
20
40
60
80
25–34 35–44 45–54 55–64 65–74
Age (years)
Any episode
of GERD
At least 1
episode of GERD
per week
females
males
Locke GR et al. Gastroenterology 1997

What are the symptoms of GERD?
Typical Symptoms
• Heartburn
• Acid regurgitation
Atypical Symptoms
• Chest pain
• Laryngitis
• Chronic cough
• Aspiration pneumonia

Risk factors of GERD
Modifiable
• Caffeine
• Chocolate
• Smoking & Alcohol
• Fatty & Spicy food
• Obesity
7
Non-Modifiable
• Hiatal hernia

What is Barrett’ esophagus
Video
9

What is Barrett’s Esophagus?
10
Squamous
Epithelium
(Normal)
Columnar
Epithelium
(Barrett’s)

What is Barrett’s Esophagus?
11
GERD
Stratified Squamous
Epithelium
(Normal Esophagus)
Specialized Intestinal
Metaplasia
(Barrett’s Esophagus)
Reflux
Esophagitis

Definition: Barrett’s esophagus
• >1cm of metaplastic columnar epithelium
replacing the normal stratified squamous
epithelium of the distal esophagus

© 2017 Virginia Mason Medical Center 13
Diagnosis: Barrett’s Esophagus
Endoscopy: >1cm
salmon color
mucosa
+
Histology:
Intestinal
metaplasia (IM)

>1cm – Why does this matter?
Segments <1cm should be classified as
“specialized IM of the EG junction”
– High inter-observer variability
– Low risk of progression to dysplasia or
EAC
Segments <1cm = “irregular Z line”
– Does not warrant endoscopic biopsy
Jung KW et al. AM J Gastroenterol 2011
Thota PN et al, Gastroenterology 2016

IM– Why does this matter?
•UK: IM is not a requirement for BE
diagnosis
- Visual evidence of salmon color mucosa
+
- Columnar metaplasia on histology
(regardless of IM)
•US: IM is a requirement for BE
diagnosis

IM– Why does this matter?
Risk of EAC in CLE w/o IM is significantly low when
compared to CLE w IM
Incidence of EAC or HGD (% per year)
– CLE w/o IM: 0.07
– CLE w IM: 0.38
ACG Guidelines: CLE w/o IM≠ BE until future
studies establish higher risk
– If you suspect BE but biopsy shows no IM: Repeat
endoscopy in 1-2 years
Bhat S et al. J Natl Cancer Inst 2011; 103: 1049.

Risk Factors for Developing BE
Symptoms:
• Chronic (>5 years) of weekly GERD symptoms
Demographics:
• Advancing age (>50)
• Male gender
• Caucasian race
• Family history
Lifestyle:
• Tobacco use
• Central obesity
Alcohol does not increase risk
• Red wine may be protective

BE - NDBE
E AC
BE - LGD
BE - HGD
Natural History of BE

BE - NDBE
E AC
BE - IND
BE - LGD
BE - HGD
Natural History of BE

GERD and Barrett’s Esophagus
21
<1 1–5 5–10 >10
Duration of GERD symptoms (years)
Prevalence of
Barrett's esophagus
(%)
0
5
10
15
20
25
Lieberman DA et al. Am J Gastroenterol 1997
~10% of patients with GERD develop Barrett’s

Why do we care about Barrett’s?
Reasons
• Precancerous lesion for
esophageal cancer
• Esophageal cancer has
poor prognosis (5 year
survival <20%)
• Incidence of esophageal
cancer is increasing
22
Norman Barrett MD

Esophageal Cancer Incidence
23
1975 19801985 19901995 2000 2005
0
5
10
15
20
25
30
Incidenceper1,000,000
Incidence
Time Trend
Pohl H. Cancer Epidemiol Biomarkers Prev 2010
3.6 per million 1973
25.6 per million
2006
7-Fold Increase
In 3 Decades

What is the risk of cancer in Barrett’s?
Cancer risk depends on
 Presence or absence of dysplasia
 Degree of dysplasia
25

What is the risk of cancer?
Barrett’s Esophagus
Is there
dysplasia?
YesNo
Low Grade High Grade
Minimal
0.3% per yr
Moderate
0.5% per yr
High
7% per yr
Cancer
Risk

Who should be screened for Barrett’s?
Chronic GERD(5 years)
+
≥1 risk factors
• Age>50
• Male
• White
• Hiatal hernia
• Obesity
• Smoking
30

How do you screen for Barrett’s?
- Upper Endoscopy
31

PPI in Barrett’s Esophagus
 Osteoporosis/hip fractures
 Interactions with antiplatelet agents,
particularly clopidogrel
 Increased incidence of community
acquired pneumonia and C. diff colitis
 Magnesium deficiency
 Diarrhea, nausea, bloating
 Kidney dysfunction
 Dementia

No
Dysplasia
Low Grade
Dysplasia
High Grade
Dysplasia
If you have Barrett’s, what’s next?
Endoscopic Monitoring
Endoscopic Treatment
Endoscopic Monitoring
Endoscopic Treatment
Barrett’s

What is endoscopic monitoring?
- Upper Endoscopy
35
+ Esophageal Biopsy

What is Endoscopic Treatment?
1. Cut Endoscopic Mucosal Resection
2. Burn Radiofrequency Ablation
3. Freeze Cryotherapy
36

CUT - EMR
37

BURN - RFA
38

What happens if I develop Cancer?
- Cancer identified in patients under
endoscopic monitoring is typically
early stage
- What is the advantage of early
diagnosis?
 Endoscopic therapy is an option
 Surgery with curative intent
(NOT palliative)
39

Early Esophageal Cancer
Intramucosal
Carcinoma
High Grade
Dysplasia

To Summarize….
• Chronic GERD is a risk factor for
Barrett’s esophagus
• Barrett’s esophagus is a risk factor
for esophageal cancer
• Monitoring/Treatment of Barrett’s
can prevent esophageal cancer
• Early esophageal cancer can be
treated with endoscopic therapy
42

Specialist presentation 4 11-19

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