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

Key points:

  • Gastroesophageal reflux disease is very common, affecting almost 30 million 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 due to chronic acid reflux and can be detected by endoscopy with biopsy.
  • Individuals with longstanding reflux should be screened via endoscopy for this condition
  • Barrett's Esophagus is associated with an increased risk of developing esophageal adenocarcinoma (a form of cancer).
  • Esophageal adenocarcinoma has been increasing in frequency in the U.S. over the past 30 years.
  • Early detection and treatment is highly desirable as this is a potentially lethal malignancy.

What is Gastroesophageal Reflux Disease?
Gastroesophageal reflux is a normal physiologic event, which occurs in all individuals. However, when this occurs frequently and an individual develops recurrent symptoms and/or complications, it is considered gastroesophageal reflux disease (GERD). It is estimated that GERD affects up to 30 million people in the U.S., with 10% of those individuals experiencing symptoms on a daily basis.

What are the symptoms of gastroesophageal reflux?
The most typical symptoms of GERD are heartburn and regurgitation. Contents of the stomach, including acid, reflux (move back up) into the esophagus, which may result in symptoms, as well as damage to the lining of the esophagus. Individuals with these symptoms are straightforward in their diagnosis. However, symptoms may be varied, including, but not limited to: chest discomfort (often difficult to discern from cardiac-related pain), asthma, cough, nausea, bad breath and loss of tooth enamel.

What are the complications of gastroesophageal reflux?
Complications of acid reflux can include dysphagia (difficulty swallowing), regurgitation, and an increased risk of cancer. This is due to progressive damage to the esophagus, resulting in inflammation, ulceration and possible scarring with narrowing. In addition, these symptoms may be indicative of esophageal cancer. All of these symptoms merit seeing a doctor for further care. At that time, the individual should undergo an upper endoscopy to evaluate the source of the problem.

How is GERD treated?
In some cases, individuals can alter their diet and take over-the-counter antacids to reduce symptoms. Dietary changes include avoiding acidic foods, fat-laden foods and overeating. Specific foods, such as chocolate, peppermints and tomato products, can exacerbate symptoms. Other lifestyle measures, such as losing weight, reducing or eliminating smoking and alcohol consumption, not eating late at night and elevating the head of the bed, may be helpful as well. Obesity is strongly associated with both GERD and its complications.

Some individuals may be on medications that promote acid reflux, such as calcium channel blockers and nitrates. However, these medications should not be stopped by a patient without consultation from their doctor.

For individuals who do not have adequate symptom improvement with lifestyle alterations, medications may be necessary. These include histamine2-receptor antagonists (H2RAs), proton pump inhibitors (PPIs) and prokinetic agents. Although H2RAs and PPIs are available over the counter, patients who have frequent GERD symptoms or use these OTC medications regularly should see a physician.

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 is --at least over the short term -- equivalent to medical therapy. The decision of medical versus surgical therapy depends on how well the patient would 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 is Barrett's Esophagus?
Barrett's Esophagus is a condition where the lining of the esophagus changes because of chronic inflammation, generally due to GERD. 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. Barrett's Esophagus itself has no specific symptoms, but this change can increase the risk of esophageal adenocarcinoma (a type of esophageal cancer). Barrett's esophagus can be readily detected during an upper endoscopy but must be confirmed by biopsies. The intent is to diagnose this condition, treat it medically, and follow it over time before cancer has a chance to develop. If biopsies detect dysplasia (a precancerous change in tissue), then your doctor will recommend either close endoscopic surveillance (doing endoscopies at regular intervals with biopsies), endoscopic therapy or surgery. Endoscopic therapy may include removal of Barrett’s with dysplasia using endoscopic mucosal resection, which can remove abnormal tissue in the esophagus without damaging the rest of the esophagus.

Endoscopic ablation of Barrett’s tissue can be done with either radiofrequency ablation, which destroys and kills cells by heating them, or cryotherapy, which destroys cells by freezing them. After treatment, the esophagus grows back a normal healthy lining. Your physician will determine which treatment option is best for you. See below for more information about ablation therapies.

Why be concerned about Barrett's Esophagus?
There are an increasing number of people per year diagnosed with esophageal adenocarcinoma in the U.S. It is thought this is related to increasing rates of obesity and acid reflux. This cancer, if detected at a late stage, has a very poor prognosis. Barrett's Esophagus is thought to increase the risk of cancer. Early detection may save lives, though that has not been definitively demonstrated.

Who should get screened 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 are more common in white males than any other demographic group. If a patient is found to have Barrett's esophagus, they should have a checkup every one to two years to monitor for dysplasia and early cancer. Early detection of esophageal cancer is associated with improved survival rates.

Mucosal Ablation Therapies
Mucosal ablative techniques are methods of destroying the superficial lining, or “mucosa,” of the gastrointestinal tract. This is usually done when the mucosa is bleeding or when there are precancerous changes which need to be treated. Once the superficial, diseased mucosal layer is destroyed, a new, healthy layer regenerates. For example, some patients have damage to the colon from previous radiation treatment for prostate cancer, with chronic bleeding from the colon lining. The lining can be ablated or destroyed, and a new lining grows back in its place. One area of considerable interest for mucosal ablation is Barrett’s Esophagus, a change in the lining of the esophagus which is sometimes found in people with chronic acid reflux disease. People with Barrett’s Esophagus are at increased risk for developing cancer of the esophagus, so they have periodic endoscopy to biopsy this lining and look for progression of the precancerous changes. If advanced precancerous changes are found, the risk of developing cancer of the esophagus is much higher, and treatment to ablate the Barrett’s Esophagus can be considered.

There are a number of devices which can be used to ablate mucosa, and the choice of a particular instrument depends on the area being treated as well as the experience of the endoscopist. These devices include catheters or probes which are passed through an endoscope and burn the GI tract lining through electricity or heat when the probe touches the lining. Another catheter conducts electricity through inert argon gas, so that the catheter does not actually have to touch the mucosa. This technique, called argon plasma coagulation, helps the physician to treat a larger area at once. Cryotherapy is a method of spraying a cold substance, usually liquid nitrogen, on the tissue. When tissue is frozen, it dies and sloughs off, allowing new, healthy tissue to grow back. Cryotherapy has been used in other parts of the body for many years (for example, to treat precancerous cells of the cervix) and is now being used in the GI tract as a means of mucosal ablation.

Another newer method of mucosal ablation, called radiofrequency ablation, has generated much interest. One radiofrequency device has been developed specifically for ablation of Barrett’s esophagus. This is a cylinder shaped balloon passed over a guidewire. Once in position it is inflated, bringing the wall of the balloon in contact with the precancerous Barrett’s mucosa. The physician presses a foot pedal and radiofrequency energy is delivered over the entire surface area of the balloon. The delivery of the energy takes about one second and results in a very superficial burn of the esophageal lining. Once the Barrett’s tissue sloughs off, a new, healthy esophagus lining grows back. There is a smaller, rectangular shaped radiofrequency instrument which can be used to “touch up” places where small pieces of Barrett’s esophagus might have been missed. The studies which have been done suggest this method of ablating Barrett’s Esophagus is safe, effective, and easy to use.

Reviewed November 2010