We searched Medline (1950–March, 2008), the Cochrane Library (1993–March, 2008), and Embase (1966–March, 2008) using the search terms “Barrett's esophagus” or “Barrett esophagus”, “specialized epithelium”, “columnar-lined esophagus”, and “intestinalized epithelium”. We also searched for “esophageal adenocarcinoma” and “adenocarcinoma of the esophagus” combined with the terms “prevention”, “pathogenesis”, “pathophysiology”, “diagnosis”, and “epidemiology”. No language restrictions were
SeminarBarrett's oesophagus
Introduction
Barrett's oesophagus is a metaplastic change of the lining of the oesophageal mucosa, such that the normal squamous epithelium is replaced with specialised or intestinalised columnar epithelium.1, 2 Intestinal metaplasia is clinically significant because it is associated with heightened risk of oesophageal adenocarcinoma, which has substantially increased in incidence in developed populations. Barrett's oesophagus is associated with symptoms of chronic gastro-oesophageal reflux disease (GERD), such as heartburn and regurgitation.3 This association led to calls for routine upper gastrointestinal endoscopy for all patients with chronic GERD to detect Barrett's oesophagus and prompt subsequent surveillance endoscopies to assess progression to cancer.4 Although such an approach is intuitively appealing, how well screening and surveillance endoscopy works is uncertain, and the associated costs are large and poorly described.5
Section snippets
Clinical presentation
The diagnosis of Barrett's oesophagus should satisfy two criteria.6, 7 First, examination by upper endoscopy should show cephalad displacement of the squamocolumnar junction. Normally, the squamocolumnar junction should coincide with the most distal extent of the tubular oesophagus (figure 1A). The intersection of the squamous epithelium of the tubular oesophagus (figure 1B) and the columnar epithelium of the stomach is termed the Z line, because of the jagged appearance of the interface.
Natural history
The risk of oesophageal adenocarcinoma in patients with Barrett's oesophagus is low, about 0·5% per patient-year,17, 18, 19 and most die with the disorder, not as a result of it. If Barrett's oesophagus does progress, it seems to do so through a series of cellular changes, ranging between non-dysplastic disease, low-grade dysplasia, high-grade dysplasia, and oesophageal adenocarcinoma. Patients with Barrett's oesophagus under endoscopic surveillance who develop cancer often do so without
Epidemiology
Barrett's oesophagus is highly prevalent in the general population and especially in people with chronic reflux conditions, but in some patients the condition is asymptomatic. Policy decisions regarding endoscopic screening and understanding of the cancer risk partly depend on the prevalence of Barrett's oesophagus in the general population. In 1990, the prevalence in Olmsted County, MN, USA, was about 376 cases per 100 000 population, from almost 1000 unselected autopsies.23 This number was
Pathogenesis
Whether Barrett's oesophagus is hereditary is unknown. Several reports suggest that a higher proportion of first-degree relatives of patients with Barrett's oesophagus have the condition than might be expected by chance,39, 44 but no gene has been identified and such data are probably subject to detection bias. The risk of both Barrett's oesophagus and oesophageal adenocarcinoma has long been known to be related to body-mass index (BMI). Increasing BMI is also associated with a statistically
Standard endoscopic screening
Endoscopy is the suggested method for diagnosis, but the results need to be confirmed by histological examination of an endoscopic biopsy specimen. Other methods such as barium study or CT do not have sufficient sensitivity for detection. Patients with chronic reflux symptoms should be screened for Barrett's oesophagus by upper endoscopy only after the patient has been on acid suppression with a proton pump inhibitor for at least 4 weeks. Although pretreatment with a proton pump inhibitor will
Management
Barrett's oesophagus is associated with a decreased quality of life compared with the general population.103 Patients misunderstand and overestimate the cancer rates associated with their condition.104 A US study105 showed that in patients diagnosed with Barrett's oesophagus, despite a life-expectancy similar to age-matched and sex-matched controls, their life-insurance premiums increased by more than 100%. Patients considering endoscopy screening for the condition should be informed of these
Future directions
The best strategy of care for patients with Barrett's oesophagus needs further elucidation. Perhaps most important is the need for risk stratification. Presently, we cannot adequately predict which patients in the large group with chronic heartburn will have the condition, and perhaps more importantly, which patients will progress from Barrett's oesophagus to dysplasia and cancer. The use of histology from endoscopic biopsy samples to assess the degree of dysplasia and risk of cancer is far
Search strategy and selection criteria
References (139)
Updated guidelines for the diagnosis, surveillance, and therapy of Barrett's esophagus
Am J Gastroenterol
(2002)- et al.
Upper endoscopy as a screening and surveillance tool in esophageal adenocarcinoma: a review of the evidence
Am J Gastroenterol
(2002) - et al.
A critical review of the diagnosis and management of Barrett's esophagus: the AGA Chicago Workshop
Gastroenterology
(2004) - et al.
Prevalence of metaplasia at the gastro-oesophageal junction
Lancet
(1994) - et al.
Long-term follow-up of intestinal metaplasia of the gastric cardia
Am J Gastroenterol
(2000) - et al.
The incidence of adenocarcinoma and dysplasia in Barrett's esophagus: report on the Cleveland Clinic Barrett's Esophagus Registry
Am J Gastroenterol
(1999) - et al.
Is there publication bias in the reporting of cancer risk in Barrett's esophagus?
Gastroenterology
(2000) - et al.
Long-term nonsurgical management of Barrett's esophagus with high-grade dysplasia
Gastroenterology
(2001) - et al.
Photodynamic therapy with porfimer sodium for ablation of high-grade dysplasia in Barrett's esophagus: international, partially blinded, randomized phase III trial
Gastrointest Endosc
(2005) - et al.
Long-term follow-up of Barrett's high-grade dysplasia
Am J Gastroenterol
(2000)
Prevalence of columnar-lined (Barrett's) esophagus. Comparison of population-based clinical and autopsy findings
Gastroenterology
Prevalence of Barrett's esophagus in the general population: an endoscopic study
Gastroenterology
Screening for Barrett's esophagus in colonoscopy patients with and without heartburn
Gastroenterology
Prevalence of Barrett's esophagus in asymptomatic individuals
Gastroenterology
The frequency of Barrett's esophagus in high-risk patients with chronic GERD
Gastrointest Endosc
Barrett's esophagus: prevalence and size of hiatal hernia
Am J Gastroenterol
The extent of Barrett's esophagus depends on the status of the lower esophageal sphincter and the degree of esophageal acid exposure
J Thorac Cardiovasc Surg
Can symptoms predict endoscopic findings in GERD?
Gastrointest Endosc
Prevalence of Barrett's esophagus in asymptomatic individuals
Gastroenterology
Barrett's esophagus: prevalence in symptomatic relatives
Am J Gastroenterol
Abdominal obesity and body mass index as risk factors for Barrett's esophagus
Gastroenterology
Central adiposity and risk of Barrett's esophagus
Gastroenterology
Association of obesity with hiatal hernia and esophagitis
Am J Gastroenterol
Functional foregut abnormalities in Barrett's esophagus
J Thorac Cardiovasc Surg
Role of acid and duodenogastroesophageal reflux in gastroesophageal reflux disease
Gastroenterology
Gastric surgery is not a risk for Barrett's esophagus or esophageal adenocarcinoma
Gastroenterology
Chemoprevention of esophageal adenocarcinoma by COX-2 inhibitors in an animal model of Barrett's esophagus
Gastroenterology
CagA-positive strains of Helicobacter pylori may protect against Barrett's esophagus
Am J Gastroenterol
Duodenal-content reflux into the esophagus leads to expression of Cdx2 and Muc2 in areas of squamous epithelium in rats
J Gastrointest Surg
The development and validation of an endoscopic grading system for Barrett's esophagus: the Prague C & M criteria
Gastroenterology
Does this patient have Barrett's esophagus? The utility of predicting Barrett's esophagus at the index endoscopy
Am J Gastroenterol
Diagnostic inconsistencies in Barrett's esophagus. Department of Veterans Affairs Gastroesophageal Reflux Study Group
Gastroenterology
Reproducibility of the diagnosis of dysplasia in Barrett esophagus: a reaffirmation
Hum Pathol
Practice patterns for surveillance of Barrett's esophagus in the United States
Gastrointest Endosc
Barrett's esophagus: a new look at surveillance based on emerging estimates of cancer risk
Am J Gastroenterol
Screening for high-grade dysplasia in gastroesophageal reflux disease: is it cost-effective?
Am J Gastroenterol
Surveillance of patients with Barrett's esophagus for dysplasia and cancer with balloon cytology
Gastroenterology
Blinded comparison of esophageal capsule endoscopy versus conventional endoscopy for a diagnosis of Barrett's esophagus in patients with chronic gastroesophageal reflux
Gastrointest Endosc
Cost utility of screening for Barrett's esophagus with esophageal capsule endoscopy versus conventional upper endoscopy
Clin Gastroenterol Hepatol
Methylene blue-directed biopsies improve detection of intestinal metaplasia and dysplasia in Barrett's esophagus
Gastrointest Endosc
Randomized crossover study that used methylene blue or random 4-quadrant biopsy for the diagnosis of dysplasia in Barrett's esophagus
Gastrointest Endosc
Enhanced magnification endoscopy: a new technique to identify specialized intestinal metaplasia in Barrett's esophagus
Gastrointest Endosc
Detection and classification of the mucosal and vascular patterns (mucosal morphology) in Barrett's esophagus by using narrow band imaging
Gastrointest Endosc
The utility of a novel narrow band imaging endoscopy system in patients with Barrett's esophagus
Gastrointest Endosc
Chromoendoscopy and narrow-band imaging compared with high-resolution magnification endoscopy in Barrett's esophagus
Gastroenterology
Endoscopic video autofluorescence imaging may improve the detection of early neoplasia in patients with Barrett's esophagus
Gastrointest Endosc
Diagnosis of specialized intestinal metaplasia by optical coherence tomography
Gastroenterology
Barrett's esophagus
N Engl J Med
Gastroesophageal reflux, Barrett esophagus, and esophageal cancer: scientific review
JAMA
The relationship between gastroesophageal reflux disease and its complications with Barrett's esophagus
Am J Gastroenterol
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