Managing reflux
The first step in managing Barrett esophagus is controlling the reflux that drives it. These patients are treated for GERD (gastroesophageal reflux disease) as any other patient with GERD is, with one difference: a proton pump inhibitor (PPI) is taken continuously, every day, irrespective of reflux symptoms. Controlling symptoms is not the only goal, because acid can still reach the esophagus when heartburn has been relieved.
The reason to keep suppressing acid is not that PPIs reverse the metaplasia — they do not. It is that PPI therapy is associated with a substantially lower risk of progression to high-grade dysplasia or adenocarcinoma, so it reduces the chance of the disease advancing as well as controlling symptoms.
Aspirin and NSAIDs
Aspirin and other NSAIDs (nonsteroidal anti-inflammatory drugs) block the cyclooxygenase pathway, a mediator of inflammation that contributes to esophageal carcinogenesis. In the Barrett mucosa they have been shown to reduce proliferation, reduce inflammation, and increase apoptosis, and people taking them appear less likely to develop adenocarcinoma. Trials have not turned this into a recommendation, because the benefit on cancer outcomes is small and uncertain while the bleeding and cardiovascular risks are real. Medical societies therefore do not recommend aspirin or NSAIDs as chemoprevention in Barrett esophagus. Many patients with the condition take aspirin anyway, for cardiovascular protection.
Treating dysplasia
Once dysplasia is present, acid suppression alone is not enough. Patients with low- or high-grade dysplasia are offered endoscopic eradication therapy — usually radiofrequency ablation to destroy the flat Barrett mucosa, with endoscopic resection of any visible nodule or mass first. Because the grade of dysplasia is read from random biopsies and decides whether this treatment is offered, a diagnosis of dysplasia is confirmed by a second expert pathologist before therapy.
Screening
Screening is not offered to everyone with reflux. The latest guidelines recommend endoscopic screening for Barrett esophagus only in patients who have multiple risk factors. In current practice this means chronic GERD symptoms plus at least 3 of the following:
- age over 50 years
- male sex
- white race
- tobacco smoking
- central obesity
- a family history of Barrett esophagus or esophageal adenocarcinoma in a first-degree relative
A hiatal hernia is a further recognised risk factor.