Gastroesophageal Reflux Disease (GERD), Barrett's Esophagus and Ablation Therapies
- 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
- Treatment can include lifestyle changes,
over-the-counter or prescription medications, surgery and possibly endoscopic
- 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
- 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.
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
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
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
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 ofthe esophagus.
How is Barrett’s
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
Reviewed August 2014