I'm a 24-year old woman who was diagnosed with Barrett's Esophagus about
six years ago. I took medication for this for about three years, but eventually
the pain and heartburn returned. It was determined that I should undergo surgery
to treat this, specifically a procedure known as a Nissen Fundoplication. Since
then, I have not had the heartburn and pain I was having.
Recently, I've noticed a slight tightness in my chest and a little pain.
My mother (who also has been diagnosed with this) told me that a new internist
informed her that the surgery doesn't "cure" Barrett's and that I should still
be checked regularly for this. I'm a little bit concerned since I haven't had
an endoscopy in about three years. Do I have anything to worry about and should
I be having endoscopies on a regular basis? Jennifer
Dear Jennifer,
As you know, Barrett's esophagus, sometimes called Barrett's epithelium, refers
to a change in the lining of the lower esophagus where the normal pinkish lining
(the epitherlium) is replaced with a darker, red lining (this looks more like
the stomach lining). It is necessary to biopsy this area because the increased
chance of developing esophageal adenocarcinoma is present only if intestinal
metaplasia (intestinal glands present on biopsies of the lower esophagus) is
noted.
There is no routine modality that is used that has been proven to reverse or
destroy Barrett's epithelium. Researchers have used specialized techniques such
as bipolar electrocoagulation (cautery), photodynamic therapy and laser treatments
to destroy Barrett's epithelium with variable success rates. Prolonged acid
suppression (with omeperzole and lasoprazole) and Nissen fundoplication have
not been consistently proven to alter Barrett's epithelium.
Therefore, it is recommended that you have surveillance endoscopies every two
years or so if it is documented that you have intestinal metaplasia.
For the past six months, I have been feeling that there is something
stuck in my throat or larynx which causes no real pain but minor difficulties
in swallowing. In addition, I frequently feel some pressure around my forehead
and temples, which causes a little spaciness and difficulty in concentrating.
I am wondering if these two symptoms are related.
I am 46 years old, a moderate tobacco and marijuana smoker, relative
non-drinker with a bad diet that includes about two cups of strong coffee per
day. After three visits to my community health clinic, where I was told I might
have chest or throat cancer, I had a chest x-ray, which was negative and then
went to an ENT,who diagnosed me with acid reflux, told me not to worry and suggested
lifestyle changes. He shone a light down my throat, described it as red and
swollen and wondered if I drank a lot or chewed tobacco. This was six weeks
ago.
Since then, I've cut back on smoking and drinking, elevated my head
in bed and am eating smaller, healthier meals. My condition is unchanged or
slightly worse and I'm becoming annoyed. Is it possible I could have something
stuck in my throat? I would like to know what's going on. Paul
Dear Paul,
There are several possible explanation for your symptoms. You may have a post-nasal
drip or sinus causing your irritation. Esophageal relux of acid can cause and
sore throat and inflammation of the oropharynx (back of the throat). Lifestyle
modifications, as you have done, improve symptoms in some people, but often
medications (inhibitors of acid secretion, prokinetic agents) are necessary
for complete relief. If possible, you should completely eliminate tobacco and
coffee for several weeks to observe if there is symptom improvement. Finally,
it is possible that you have an incoordination of the esophageal muscles that
is causing the swallowing difficulty and sensation of something being stuck
in your throat.
To exclude these various possibilities and to determine if there is specific
therapy for your symptoms, you should be assessed by a gastroenterologist. If
an upper endoscopy was not done, you should have this test. An esophageal motility
study may also be necessary.
I have GERD, a slight hiatal hernia and a recent endoscopy revealed Barrett's
Epithelium. Is this different than Barrett's Esophagus? Also, I have been on
20 mg. of Prilosec daily for the past seven months and my doctor is continuing
this indefinitely. I've read that there have been no studies regarding long-term
use of Prilosec. Is this the best treatment for my condition? Tim
Dear Tim,
Barrett's epithelium is a term used to describe a change in the lining of
the lower esophagus. Normally, the esophagus is lined by pink, squamous type
epithelium (lining) and the stomach is lined by darker, reddish, columnar type
epithelium. When the lower esophagus is damaged by acid, its pink lining can
be replaced by the darker, reddish lining.
If the lining on biopsy appears more like the intestinal lining, it is called
intestinal metaplasia. Intestinal metaplasia has been associated with the development
of esophageal adnocarcinoma (cancer) of the lower esophagus. For all practical
purposes, Barrett's esophagus and Barrett's epithelium are the same thing.
Omeperazole (Prilosec) has been used in patients with gastroesophageal reflux
(GERD) in Europe for long periods of time (at least 3 to 5 years) without any
apparent complications.
Although some studies have shown the regression of Barrett's epithelium with
long-term use of this drug, I don't believe it occurs in most patients and I
would not recommend its use solely for that purpose. The rationale for using
omeperazole on a long-term basis is to prevent further acid damage to the lower
esphagus and thereby limit esophagitis (inflammation of the esophagus) and control
symptoms.
My 15-year old son was diagnosed with Barrett's recently. He is taking
20 mg. of Prilosec two times a day. As he also has an acne problem, his dermatologist
wants to treat him with Accutance since all other treatments and medications
have failed.
Neither the gastroentorologist or the dermatologist had advised me about
whether there are any problems in taking Accutane with his condition. A recent
PH probe test showed Prilosec controlling the acid for 23 out of 24 hours. Are
there any problems with his taking Accutane and should we watch for any specific
symptoms? Any information you have would be appreciated. Arty
Dear Arty,
Accutane (isotretinoin) remains the most effective anti-acne therapy available.
Since it was approved for the treatment of severe acne in the early 1980s, more
that 7 million patients have received this medication.
The most common side effects of Accutane are dryness of the mouth, nose and
eyes. It also commonly produces some redness of the facial skin with increased
sensitivity to ultraviolet light.
About 15% of the patients taking Accutane complain of some muscle or joint
pain, usually relieved with over-the-counter analgesics like Tylenol.
Because in some rare cases, patients taking Accutane developed abnormal liver
blood tests and high cholesterol, most physicians routinely check these blood
tests before starting treatment.
Accutane has also been safely used in many chronic diseases such as inflammatory
bowel disease (ulcerative colitis and Crohn's disease), epilepsy, diabetes,
multiple sclerosis, renal insufficiency and heart or kidney transplant patients.
Using a computerized medical literature database, we could not find any references
to Accutane treatment in Barrett's Disease or interactions between Accutane
and Prilosec.
Despite the lack of specific information about the use of Accutane in patients
with Barrett's esophagus taking Prilosec, it is probably safest to remain under
the supervision of your Dermatologist.
I'm 40 years old and have had reflux for the last five years. I have
been taking Prilosec for three of those years. When I went for an endoscopy
three months ago, they found out I had Barrett's Esophagus with pre-cancer cells
at that point.
My doctor said I should undergo surgery to have my whole esophagus removed
and this scares me. So I went for a second opinion, and that doctor said there
are other steps to take before surgery, such as laser treatment, freezing those
cells or just a higher dose of Prilosec (e.g., 80 mg. per day) and just keep
having endoscopies every three months.
Is 80 mg. of Prilosec too much and is three years too long to be on
this medication? Are there any new options for me? Karl
Dear Karl,
The next step in your care depends on the degree of premalignant change. If
you have low grade dysplasia, then higher doses of Prilosec or laser therapy
is worth a try. If you have high grade dysplasia, you may want to consider surgery.
Some surgeons are reporting an operation that removes the mucosa (inner lining)
of the esophagus without removing the whole organ. You may want to ask you physician
about this option, if your dysplasia is moderate or high grade.
Prilosec at 80 mg. per day is a high dose but should not present a problem
in the short term. There is no danger in being on Prilosec for three years.
My husband has had Barrett's for eight years and has an endoscopy every
two years to assess malignancy. No malignancy has been evident to date. He has
watched his diet and alcohol intake and has been on a prescription of 40 mg.
of Pepcid two times daily for the eight years. This has been quite successful
in controlling the symptoms.
His internist recently prescribed Prilosec and said if it was successful,
he might take him off the Pepcid. I understand that Pepcid is an acid blocker
and Prilosec is a neutralizer.
My husband would like to discontinue the Pepcid as we heard recently
that long term use could affect testosterone levels and my husband has experienced
evidence of that. What is your opinion regarding this change? Jan
Dear Jan,
The cause of Barrett's Esophagus is unclear, but current theory attributes
the mucosal change to chronic exposure to gastric acid. The treatment of Barrett's
esophagus, therefore, is directed towards suppression of gastric acid secretion.
Gastric acid secretion suppressants include proton pump inhibitors such as
Prilosec and Prevacid, and H2 receptor inhibitors such as Pepcid, Zantac, Axid
and Tagamet.
Prilosec and Prevacid are more potent suppressors of acid production than the
H2 receptor inhibitors. Therefore, Prilosec and Prevacid would be the treatment
of choice in reducing gastric acid secretion.
However, higher than usual dose of Pepcid (40 mg bid) as your husband has been
receiving, may also achieve the same gastric acid suppression effect.
Currently, there is no published data or literature to indicate that long term
use of Pepcid would affect male testosterone level or its biological function.
If your husband has experienced sexual dysfunction, we recommend that he see
his internist or endocrinologist regarding this issue.
Why do patients with Barrett;s esophagus require repeated upper endoscopy?
Endoscopic surveillance is necessary because Barrett's esophagus can develop
into a malignant neoplasm of the esophagus. Detection of early changes suggesting
evolution into cancer will allow for treatment to be initiated.
After an endoscopy, I have been told that I have "ectopic gastric mucosa,"
or cells in my upper esophagus that secrete acid-like stomach cells. I'm told
that I was born with these cells, as opposed to having Barrett's Esophagus.
I was also told this condition is fairly common, but I cannot find any
references on the Web to such a condition.
My discomfort responds to Prevacid, but not to Zantac. It also responds
to Pepto-Bismol chewable tables, but not to the new Pepto-Bismol capsules, which
all seems to agree with the idea that the source of irritation is in the upper
esophagus. Can you tell me more about this condition or where to look for more
information? Wayne
Dear Wayne,
Columnar mucosa in the upper esophagus is a benign condition present since
birth. Unlike Barrett's esophagus, this condition is not associated with the
subsequent develoment of esophageal cancer.
Usually, there are no symptoms associated with this condition. Therefore, I
am surprised by your history of pains. Are your doctors certain that the ectopic
mucosa is the cause of your symptoms?
With regard to therapy, we would recommend using the medications which you
know are effective. Finally, we are unaware of any web sites that would provide
additional information regarding this condition.
I am a 51-year old female who has had Crohn's Disease since I was 20.
I have been very fortunate in that I have not had a lot of problems since age
30.
Two years ago, I had terrible problems with my esophagus. The gastroenterologist
ran an endoscopy on me as he was convinced I had Barrett's, but the lab reports
said this was not the case.
I went back for a two-year check, but also informed him that for several
months I've had problems with pain in my abdominal area. He still feels I have
Barrett's, but we are waiting for reports to come back. The pain is still really
bad in the abdomen, but different from earlier years of the onset of Crohn's.
Presently, my physician has me on 30 mg. of Prevacid two times a day
and .125 mg. of Hyoscyamine two times a day. I am very confused.
Since Crohn's can go anywhere in the digestive tract, I worry about what
is going on in my esophagus, and if it is perhaps spreading to the small bowel.
Most of the pain is centered near the navel, but is all over the intestinal
area and even my stomach gets sore.
Adding to my worry is the fact that two years ago, my doctor informed
me that biopsies from my colonoscopy showed I have pre-cancer cells present.
Could all these things be related? I have ignored pain for many years
and just accepted it, but now the pain is too much to ignore. I am also so tired
out that I just drag in everything I do. I really do appreciate any information
you can give me. Carole
Dear Carole,
You are correct that Crohn's Disease can involve the entire GI tract from
mouth to anus. Sometimes, physicians can have difficulty confirming active disease
and therefore there is a delay in starting treatment.
Your e-mail raises several interesting issues. Barrett's esophagus and Crohn's
Disease can both involve the esophagus although there is no compelling evidence
that one condition predisposes to the other.
Biopsies of the esophagus can determine conclusively whether you have Barrett's
esophagus. It can be more difficult to distinguish between Crohn's involvement
of the esophagus and reflux esophagitis. An empiric trial with antireflux treatment
including medication (Proton pump inhibitors e.g Prilosec and prokinetic agebts
e.g. Cisapride) is indicated.
You do not state if you had small intestine and/or colonic Crohn's Disease
or whether you have required surgical intervention. Your complaints of diffuse
abdominal pain and fatigue may represent a flare of your Crohn's disease, although
other conditions must be considered. At this juncture it would be appropriate
to have barium studies of your small intestine. Finally, the colonic precancer
cells may be related to the Crohn's Disease.
My 15-year old son was just diagnosed with Barrett's Esophagus. He has
undergone endoscopy and a biopsy and is currently taking 20 mg. of prilosec
two times a day.
I am trying to locate information on this problem in children as well
as on treatments, frequency of follow-up endoscopies, etc. His doctor is planning
a PH study after six to eight weeks on medication to determine if it is helping.
If acid levels are reduced, what are the possibilities of this becoming malignant?
Any information you can give me would be helpful as his doctor is unfamiliar
with this problem in teenagers. Arty
Dear Arty,
The diagnosis of Barrett's Esophagus can be difficult to make in children.
Careful endoscopy with multiple biopsies are necessary to confirm the diagnosis.
The pathologist should see specialized mucosa with goblet cells. The number
of cases of malignancy in children with Barrett's esophagus is low. Of these
cases, most had the cancer at the time Barrett's was diagnosed. Also, there
are no scientific criteria to direct the frequency of screening and most approaches
rely on anecdotal data. One author recommended the following approach:
Endoscopic surveillance is suggested only for patients who have specialized
intestinal changes.
Treatment with potent acid suppresors (as are being used for your son)
should be tried for three months. Healing of inflammation will reduce the
chance that cellular changes associated with inflammation are being confused
with premalignant changes.
Endoscopic surveillance should be performed every two to three years although
each case must be evaluated separately. There are a number of requirements
regarding the locations of esophageal biopsies that are familiar to your physician.
Finally, there has not been well-documented cases that suggest that either
medical or surgical treatment causes complete regression of Barrett's esophagus
and the return of normal lining. We hope this information will provide you with
answers to some of your questions.
My mother was diagnosed with Barrett's Disease about a year ago. She
also has Alzheimer's and I believe she is in stage 2.
She is scheduled for diagnostic endoscopies once a year to check for
esophageal cancer. The endocrinologist she was seeing left and she is scheduled
for her next endoscopy in a week, but her new endocrinologist told us he doesn't
want to perform the procedure if we won't allow him to do surgery if he finds
cancer. He really didn't give us an explanation as to what surgery would involve
and what the impact on her life would be.
I've read some of the your responses in the Forum and see that there
are alternatives to surgery. It seems to depend on the situation as to what
the best treatment is. I was particularly intrigued by laser surgery and wondered
how effective that has proven to be and what the survival rates tend to be as
opposed to conventional surgery if the cancer is caught early.
Unfortunately, in my mother's case symptoms are hard to pin down with
her Alzheimer's, although she frequently complains of chest pains. That is how
they discovered the Barrett's. She is also seeing a cardiologist, who thinks
she may have had a heart attack in the past year. She's taking a number of medications
between the Alzheimer's, Barrett's disease and possible heart trouble. My main
concern is the new endocrinologist's attitude. I'd appreciate any comments or
suggestions you may have. Cindy
Dear Cindy,
Thank you for your questions regarding Barrett's esopahgus. Screening endoscopy
is done to identify premalignant changes in the esophageal mucosa, that is to
identify abnormal cells before a cancer develops. When premalignant abnormalities
are seen, the physician will suggest that the abnormality be removed. This approach
is based on the clinical observation that once esophageal cancer develops, death
usually occurs within one to two years.
Surgical resection has been the conventional treatment for the premalignant
lesions of Barrett's esophagus, assumimg that the patient is a good surgical
canditate. However, there are other options now. Specifically, the use of PDT
therapy with laser has been shown to eliminate the premalignant condition.
I do not know your mother's age or any information regarding her general medical
condition, except for the Alzheimer's disease. Hopefully, your mother will not
develop any premalignant changes. If she does develop abnormalities, endoscopic
laser therapy would be valuable, although several treatments may be necessary.
If you believe that you do not want to do any therapy (surgery or laser) should
premalignant conditions be identified, then you should consider discontinuing
the annual screening studies because they do not add any value to your mother's
care.
My husband has recently been diagnosed with Barrett's Esophagus, but
we have not had our follow up visit as we are waiting on results of biopsies
and our doctor is out of town. He did say that the Barrett's has been there
for some time and the examination sheet shows "severe reflux, induced lining
change and imitation (Barrett's epithelium)."
I have thought for some time now that he may have cancer as he has been
sick on and off for quite a while. He vomits several times a week, has constant
pain, mostly on the right abdominal side and has felt at times that he is choking
or cannot get enough air, mostly at night after going to bed.
We have waited four weeks and are finally seeing the doctor this week.
One minute I think he's very sick and the next I'm not really sure. He has not
been able to work because of his increased symptoms. What should I be looking
for? What should we ask the doctor? Thank you. Bonnie
Dear Bonnie,
The majority of patients with Barrett's esophagus do not develop esophageal
cancer (of the adenocarcinoma type) but the risk of developing esophageal cancer
is much higher in patients with Barrett's when compared to the general population.
Therefore, the current recommendation is to perform surveillance endoscopy
approximately every one to two years. The purpose of the surveillance endoscopies
is to look for subtle changes in the cells of the esophageal lining which indicate
malignant transformation. These changes are called dysplasia. Dysplasia can
be classified as low grade or high grade. High grade dysplasia usually requires
further management. Low grade dysplasia may signify more frequent surveillance.
Your husband's symptoms of vomiting, right sided abdominal pain and a choking
sensation after going to bed are suggestive, but not necessarily diagnostic,
for gastroesophageal reflux.
Barret's esophagus is a consequence of prolonged damage to the lower esophageal
lining from acid produced in the stomach and refluxed back into the esophagus.
Barrett's esophagus may also be accompanied by inflammation in the lower esophagus
called esophagitis. Many treatments including lifestyle modifications and medications
are available to treat gastroesophageal reflux and its complications. Your doctor
can help you with a medical regimen that is right for you. You should also ask
your doctor if he feels that surveillance endoscopy is warranted, whether or
not dysplasia is present and if so is it low grade, high grade or indefinite
for dysplasia.
It is often difficult to predict whether a person has cancer based solely on
symptoms. Nevertheless, symptoms that you should not ignore include: severe
vomiting and abdominal pain, dysphagia (difficulty swallowing), weight loss
and bleeding (both vomiting blood, rectal bleeding or black stools).
Good luck to you and we hope this information is helpful.
I have Barrett's esophagus and have been told to stay away from
fatty and acidic foods. I am looking for a list of foods that are considered
acidic. I have been told about citrus and tomatoes, but wondered about others.
I am 41 years old, 6'1" tall and 165 pounds. I am very active and run 18 to
20 miles per week. My GERD is controlled with medication, so my biggest concern
now is proper diet. Any help you can provide me is greatly appreciated. Dennis
Dear Dennis,
Certain foods can increase reflux by causing relaxation of the lower esophageal
sphincter (LES). Caffeinated beverages, carbonated drinks, cigarettes, alcohol,
fatty foods, mints and chocolate can all aggravate LES incompetence and reflux
symptoms. Moreover, foods that stay in the stomach longer (such as fried, or
fatty foods) tend to increase reflux symptoms and the amount of acid that enters
the esophagus.
It is unclear whether "acidic" food cause increased acid production in the
stomach. Although acidic food may worsen symptoms by irritating the already
injured lining of the esophagus, they probably do not alter the severity or
course of reflux disease and Barrett's esophagus.
However, be pragmatic. Do no eat foods that cause you discomfort. Once the
active inflammation of the esophagus has healed, you may find that you can tolerate
certain "acidic" foods again.
If you refrain from taking caffeinated beverages, carbonated drinks, cigarettes,
alcohol, fatty foods, mints and chocolate, your symptoms should improve considerably
and you will facilitate healing of esophageal inflammation.
In addition, since reflux is more likely to occur when lying flat, raising
the head of the bed prevents stomach fluid from flowing back into the esophagus.
Generally, raising the bed four to six inches is recommended. Books or blocks
under the legs of the bed or a wedge under the mattress can be used.
Since stomachs full of food and acid are more likely to reflux, avoiding bedtime
snacks and eating meals at least three to four hours before lying down can help
reduce reflux. The above measures will probably be more advantageous than abstaining
from "acidic" food.
Lastly, persons with severe reflux disease and persons with Barrett's esophagus
should take medications to suppress the acid production by the stomch, in addition
to the measures outlined above.
You are doing all the right things to take good care of your body. Keep up
the good work.
I have been diagnosed with Barrett's esophagus
and as having a hiatal hernia. I pretty much have the acid reflux problem under
control due to lifestyle changes, but I am wondering if the cell damage done
to my esophagus is reversible. I know this is considered a premalignant condition
and would like to know that one day this worry will be gone. Thank you. Candace
Dear Candace,
We assume that your Barrett's esophagus was diagnosed by a test called an
endoscopy with biopsy of the esophageal mucosa. Barrett's esophagus is the result
of acid reflux from the stomach into the esophagus, resulting in damage to the
lining with replacement of the normal lining by an abnormal cell type. You are
correct that this is a premalignant condition. Fortunately, few people develop
cancer.
It is controversial whether Barrett's esophagus can revert to a normal lining
(mucosa). Medical or surgical therapy, however, can heal the esophagitis or
acute inflammation.
Currently patients with Barrett's esophagus are screened by endoscopy and biopsy
every two years to verify that there has been no evolution towards malignant
change of the mucosa. Therefore, we would advise you to maintain in contact
with your physician.
You should also be aware that there are new endoscopic treatments to treat
these early premalignant chages. A technique called photodynamic therapy is
being investigated to determine its efficiency in the destruction of this abnormal
mucosa.
