Barrett oesophagus

What it is

Barrett's esophagus is metaplasia of the normal squamous esophageal epithelium to intestinal columnar epithelium, that is intestinal metaplasia, and it is a risk factor for adenocarcinoma. It is the most important complication of chronic gastroesophageal reflux disease and a precursor to esophageal adenocarcinoma.

Causes and risk

Chronic reflux is the cause. Among the complications of reflux disease it sits with esophagitis, ulcer, bleeding, esophageal stricture disease whose scarring can lead to dysphagia for solids, and esophageal adenocarcinoma. The risk factors that count for adenocarcinoma of the esophagus are reflux disease, Barrett's esophagus, obesity and male sex. Set among the lesions that predispose to carcinoma of the esophagus, Barrett's esophagus is placed at moderate risk alongside achalasia, reflux esophagitis, radiotherapy and ectopic gastric mucosa; tylosis and Plummer-Vinson syndrome are placed at high risk, and scleroderma, stricture, coeliac disease and diverticulum at low risk.

Where it sits in the dysphagia table

Barrett's oesophagus appears once more at the end of a table of the causes of dysphagia, at the end of a disease that takes the lower oesophagus: the lower oesophagus is often affected, resulting in poor peristalsis, severe GORD with stricture formation and Barrett's oesophagus. The rest of that table is what the same patient is weighed against.

• Neoplastic: oral cavity, oropharyngeal, hypopharyngeal, laryngeal and oesophageal tumours can present with dysphagia, with weight loss and symptoms of aspiration like cough and recurrent chest infection. The patient may only complain of a feeling of something in the throat, like a crumb being stuck, with referred otalgia. Dysphagia of short duration in an elderly male who smokes and drinks, and which progresses from solids to liquids, is typical for oesophageal carcinoma. External compression of the oesophagus due to goitre and thyroid malignancies belongs here too.
• Oesophageal motility disorders: in achalasia cardia the lower oesophageal sphincter fails to relax and allow food to pass into the stomach, caused by degeneration or absence of the ganglion cells, the myenteric plexus of Auerbach. Patients present with difficulty in swallowing fluids initially and progressively difficulty with solids, and barium swallow will demonstrate a bird's beak tapering on the oesophagogastric junction with dilatation of the lumen above it. In diffuse oesophageal spasm there are non-effective peristaltic waves of high amplitude in the oesophagus, causing angina-like chest pain, and barium swallow and manometry demonstrate non-propulsive peristaltic waves and incomplete lower oesophageal sphincter relaxation.
• Neurological: a cerebrovascular accident gives cricopharyngeal dysfunction with reduced tongue control and pharyngeal contraction and cough. Parkinson's disease gives dysphagia associated with changes in striated muscle under dopaminergic control and smooth muscle under autonomic control, with abnormalities in the oral preparatory and pharyngeal phases of swallowing.
• Post-treatment: patients who have undergone treatment for head and neck cancer often suffer significant dysphagia and aspiration, and chemoradiotherapy can cause xerostomia, reduced tongue strength and control, decreased tongue base movement, decreased laryngeal elevation, reduced epiglottic inversion and delayed pharyngeal swallow.
• Miscellaneous: globus pharyngeus, a foreign body sensation in the throat or a lump in the throat, is a diagnosis of exclusion, and flexible nasendoscopy, transnasal oesophagoscopy and barium swallow tests should be done to exclude other causes.