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Gastroesophageal Reflux Disease (GERD), Barrett's Esophagus and Ablation Therapies

Key points:

  • Gastroesophageal reflux disease is very common, affecting 20% of Americans.
  • Classic symptoms include heartburn and regurgitation. Other symptoms may include chest discomfort, asthma and/or a cough.
  • Treatment can include lifestyle changes, over-the-counter or prescription medications, surgery and possibly endoscopic therapies.
  • Barrett's esophagus is a change in the lining of the esophagus caused by chronic acid reflux and can only be detected by upper endoscopy with biopsy.
  • Barrett's esophagus is associated with an increased risk of developing esophageal adenocarcinoma (a type of cancer of the esophagus).
  • Esophageal adenocarcinoma has been increasing in frequency in the U.S. over the past 30 years.
  • Individuals with longstanding reflux should be screened via endoscopy for Barrett’s esophagus
  • Early detection and treatment is highly desirable as this is a potentially lethal malignancy.

What is Gastroesophageal Reflux Disease?
Gastroesophageal reflux disease (GERD) is a condition which develops when the reflux of stomach contents (including acid) causes troublesome symptoms and/or complications including damage to the lining of the esophagus. It is estimated that GERD affects up to 20% of adults in the U.S. who experience symptoms on a daily to weekly basis.

What are the symptoms of gastroesophageal reflux?
The most common and typical symptoms of GERD are heartburn and regurgitation. Heartburn is a burning sensation in the lower chest just behind the breastbone that can extend upward; it is worsened by bending or lying down. Regurgitation is the sensation of food or sour liquid refluxing back into the esophagus. Individuals with these classic symptoms have a straightforward diagnosis. However, symptoms may be varied and also include: chest discomfort (which may be difficult to discern from cardiac-related pain), asthma, cough, nausea, bad breath and chronic hoarseness.

How is GERD treated?
Initial treatment of GERD includes lifestyle modifications, dietary changes and over-the-counter antacids. Elevating the head of the bed and refraining from eating at least two hours before bedtime can be helpful for those with nighttime symptoms. Dietary changes include avoiding overeating, particularly acidic and fat-laden foods, and eliminating or reducing smoking and alcohol consumption. Specific foods, such as chocolate, peppermints and tomato products, can exacerbate symptoms, but sensitivities vary widely among patients. Obesity is strongly associated with both GERD and its complications and weight loss is recommended.

For individuals who do not have adequate symptom improvement with the above lifestyle alterations, medications may be necessary. These include histamine 2-receptor antagonists (H2RAs) and proton pump inhibitors (PPIs) which are available over the counter and by prescription. Patients who have frequent GERD symptoms or use these OTC medications regularly should see a physician. Proton pump inhibitors decrease gastric acid secretion more completely and are used more often in patients with more severe GERD.

Surgical therapy is available for those who do not respond to lifestyle and medication therapy or who do not wish to remain on medications. Surgery consists of wrapping the top of the stomach to reform the natural acid barrier and fixing the defect in the diaphragm and hiatal hernia if present. This type of surgery is called a fundoplication. Surgical therapy and medical therapy are generally equally effective. The decision of medical versus surgical therapy depends on how well the patient is likely to tolerate surgery, their response to medical therapy and the underlying causes of the GERD. In addition, there are several endoscopic treatments for GERD. However, these are still relatively new and, for the most part, unproven or still investigational.

What are the complications of gastroesophageal reflux?
Complications of acid reflux can include esophageal strictures (narrowing), ulcerations and Barrett’s esophagus, which is a precancerous change in the lining of the esophagus. Symptoms of complications of GERD include: dysphagia (difficulty swallowing), odynophagia (pain upon swallowing), refractory heartburn, anemia, vomiting or weight loss. Any of these symptoms merit seeing a doctor for further care. At that time, the individual should undergo an upper endoscopy to help evaluate the source of the problem.

What is Barrett's esophagus?
Barrett's esophagus is a condition where the lining of the esophagus changes due to GERD and this change increases the risk of esophageal adenocarcinoma. It is believed to be a reparative response to reflux induced damage to the normal squamous lining of the esophagus, with subsequent replacement with Barrett’s esophagus. In other words, in the setting of chronic acid exposure, the cellular structure of the lower esophageal lining changes to look more like the cells lining the intestine. However, Barrett's esophagus itself produces no specific symptoms different from those of standard GERD

Why be concerned about Barrett's esophagus?
There is an increasing number of people per year diagnosed with esophageal adenocarcinoma in the U.S. Barrett's esophagus is the primary risk factor for this type of cancer perhaps related to increasing rates of obesity and acid reflux. Esophageal cancer, like most cancers, when detected at a late stage has a very poor prognosis. Detection at earlier stages has a better prognosis and screening and surveillance for Barrett’s esophagus may save lives, though that has not been definitively demonstrated.

How is Barrett’s esophagus diagnosed?

The only way to detect Barrett's esophagus is to undergo upper endoscopy where Barrett’s esophagus can be confirmed by biopsies. The intent of screening for Barrett’s esophagus is to diagnose this condition, treat it as needed and follow it over time to detect dysplasia or early cancer. If biopsies detect dysplasia (a worsening precancerous change in tissue), then your doctor may recommend either closer endoscopic surveillance (doing endoscopies with biopsies at shorter time intervals) and/or endoscopic therapy to remove the abnormal tissue.

Who should get screening and surveillance for Barrett's esophagus?
It is recommended that individuals with longstanding reflux (longer than 5 years) should undergo screening for this condition. Barrett's esophagus and esophageal cancer is also more common in older patients (> age 50) and in Caucasian males. If a patient is found to have Barrett's esophagus without dysplasia, they should have a surveillance endoscopy every three to five years to monitor for dysplasia and early cancer. Surveillance endoscopy intervals for Barrett’s esophagus with dysplasia are even shorter. Early detection of esophageal cancer is associated with improved survival rates. See Table 2 regarding surveillance in ASGE’s guideline The role of endoscopy in Barrett’s esophagus and other premalignant conditions of the esophagus.

How is Barrett’s esophagus treated?
Patients with Barrett’s esophagus have GERD and should be treated for GERD, as noted above, usually with proton pump inhibitors. Endoscopic therapy can eradicate Barrett’s esophagus with or without dysplasia. Endoscopic therapy can be divided into therapies that ablate mucosa and techniques that resect mucosa. A key element of the endoscopic therapy of Barrett’s esophagus is that re-epithelialization with normal squamous mucosa (that is, return of the esophagus lining to normal tissue) can only be achieved in an acid-suppressed environment; thus, the use of anti-secretory agents or anti-reflux surgery is a necessary adjunct to these techniques.

Mucosal ablative techniques are methods of destroying the superficial lining, or “mucosa,” of the gastrointestinal tract. The most common method of mucosal ablation destroys and kills abnormal cells by heating them using thermal energy called radiofrequency ablation (RFA).  RFA can be delivered using cylinder shaped balloons or touch pads passed into the esophagus under endoscopic guidance. Multiple studies have demonstrated that this is a very safe, effective method to treat Barrett’s esophagus. Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are endoscopic techniques designed to remove targeted superficial tissue of the GI tract (EMR) or large en bloc strips of mucosa (ESD). Both techniques actually remove abnormal tissue (rather than ablate it) in the esophagus and allow for full pathological evaluation. Your gastroenterologist can help determine if and which type of endoscopic treatment option is best for you.

Reviewed August 2014