What Is Barrett’s Esophagus And Why Does It Cause Cancer?
There are three things you need to know about Barrett’s Esophagus to understand how it puts you at risk for cancer of the esophagus. First, there is the very peculiar transformation of the lining of the lower esophagus into cells that would seem more at home in the small intestines. That metamorphosis is the first step in driving a progression to a very life-threatening cancer. Second, the chronically acid damaged cells of the lower esophagus are driven to this transformation by repetitive injury. Damage followed by repair, more damage, repair, over and over again until the repair isn’t quite right. The sun-lovers at the beach have repetitive damage to the skin until decades later, a skin cancer develops. That repetitive injury, and oxidative stress is handled by the body 99.99% of the time, but when it fails, changes in the cells take place causing the normal esophagus lining to be replaced by Barrett’s esophagus. Finally, and most importantly, you can prevent cancer by stopping the repeated acid damage to your esophagus and by appropriate endoscopic monitoring. Yes, I said prevent cancer. It is not good enough to find early cancer. Prevention is truly available and achievable if you arm yourself with the right information. So read on and learn what you need to know to save your life!
Detecting Barrett’s Esophagus Can Save Your Life!
The diagnosis of “Barrett’s esophagus” has often created a great deal of anxiety. After all, there is a high risk of developing esophageal cancer in patients with Barrett’s esophagus, and survival with esophageal cancer was poor. Esophageal cancer of the junction of the esophagus and stomach is the cancer rising at the fastest pace with an 800% increase in the past three decades. It is caused by reflux of stomach contents into the esophagus called Gastroesophageal Reflux Disease, also dramatically increasing in recent years.
Let’s Visit The Case Of A Real Person Presenting With Barrett’s Esophagus
Take this story of a true patient. Jim, is a 69 year old man who doesn’t like to see doctors. He is a former smoker, and retired salesperson. He often ate meals out and in a hurry, and had plenty of TUMS to relieve his heartburn. They always seemed to help, but now he is experiencing a sticking sensation in the low chest. He still would not have come to the doctor, but his daughter insisted that he come to the Reflux Care of New York.
Dr. David Gutman diagnosed Gastroesophageal Reflux Disease (GERD), and recommended an endoscopy of the Esophagus, Stomach, and Duodenum (EGD). The endoscopy showed a hiatal hernia, erosions of the lower esophagus and fingers of a dark pink lining weaving into the salmon color of the esophagus. Dr. David Gutman recognized this finding of abnormal tissue in the lower esophagus as Barrett’s Esophagus, and took biopsies to check for any precancerous cells called dysplasia. Using Hi-Definition endoscopy with Narrow Band Imaging, a technique that uses prismatic light to contrast abnormal cells, Dr. Gutman noticed that what appeared flat in the ordinary white light of the endoscope, appeared as a raised bump on the Narrow Band Imaging. Biopsies revealed precancerous cells called “high grade dysplasia.”
There’s a lot to digest in this real life presentation, so we will dive into what the take home messages are. First, and foremost, is the notion that heartburn should not be self-medicated without appropriate diagnosis and therapy by an expert physician. We have been indoctrinated by commercials “plop-plop, fizz-fizz,” “how do you spell relief,” and “Maalox moments” that we presume this to be a minor matter requiring only treatment of symptoms with widely available over the counter remedies. When I was involved with the development of Pepcid Complete, I would fill a large cafeteria nightly with people who all told the same story. “I use TUMS a few times a day, almost everyday.” This is dangerous! Yes, you can self-medicate after going to a wedding and eating too much, drinking too much, and lying down too soon after eating. Not every day. Listen to your body. It is calling for attention. The need for antacids or symptoms occurring more than twice a week demands medical attention. Again self treatment leads to erosions and cancer.
Repetitive Damage and Repair Causes Cancer Of The Esophagus
Second, is that symptoms of food sticking as Jim had are serious signs. You can have severe damage as erosions in the esophagus without significant symptoms, but not listening to the alarm bells will be dangerous. People under 40 can be treated without testing. Symptoms of choking during the night, swallowing difficulty or pain on swallowing, weight loss, chest pain resembling a heart attack, or anemia, should be evaluated with diagnostic testing with endoscopy. Esophageal Manometry or acid pH testing should be utilized in the appropriate patients.
Why Is Endoscopy So Important In Barrett’s Esophagus?
Endoscopically, the diagnosis of Barrett’s esophagus, is relatively easy to the experienced endoscopist. The lower esophagus is covered by a pale pink or salmon colored tissue called mucosa. The mucosa of the stomach is quite a deeper red color. The junction of the esophagus and the stomach is a smooth ring with a crisp line between the esophagus and the stomach. When the lower esophagus has fingers or islands of the darker color strewn into it, We call it Barrett’s esophagus. The biopsies show the fingers to have intestinal tissue which is quite different than either the esophagus or stomach lining cells. Here in the esophagus, the lining is by a specialized mucosa unlike the surrounding normal tissue. The scarf goes into the magician’s hat and is transformed into a white rabbit. How does this transformation called metaplasia occur? It seems like alchemy, turning iron into gold! In fact, the blueprint for every cell in your body is identical. The genes in your body are on 46 strands of DNA called chromosomes. Almost all the cells are identical, except the sperm and eggs, because they have only 23 chromosomes, while the other cells have 23 pairs of chromosomes. So if all the cells have the same genes, then how is it that a liver cell and a bone cell are so much different? The answer is context. Context tells cells to produce the proteins that make skin the protective layer that it is and not to secrete acid like a stomach cell. That context is created when the embryo develops, but can be changed by damaging elements like oxidative stress and injury.
What Does Oxidative Stress Do To The Cells Of The Esophagus?
Oxidative stress in the lungs from smoking causes cells to change into the uncontrolled growth of a lung cancer. The body is prepared to withstand injury to a point. Cells turn over and damaged cells are removed by programmed cell death. Injury to the skin by oxidative stress from the sun leads to sunburn, but then the cells die and are replaced by new cells. This remarkable method of healing damage by repair works over 99.99% of the time!
But what happens when after repeated injury and oxidative stress, the cells are repaired incorrectly? Programmed cell death (apoptosis) eliminates these abnormal cells very efficiently. Sometimes the injury is so overwhelming that we get cancer (neoplasia), precancerous cells (dysplasia), or alteration of the cells to a new form (metaplasia).
In Barrett’s esophagus, we can see all three of these changes, and the difference is key. Barrett’s esophagus is metaplasia into these specialized intestinal cells. It is not precancerous. So many times I have heard people refer to Barrett’s as precancerous causing people to worry that they will get cancer. The time to worry is before you first see the gastroenterologist and have your first endoscopy of the esophagus and stomach (EGD).
I have never seen anyone develop cancer after they were diagnosed as having Barrett’s. How could that be, when we see so many patients with Barrett’s at the Reflux Care of New York? To be precancerous you need dysplasia before you develop cancer. We have seen many whose very first endoscopy showed dysplasia or invasive cancer on the very first endoscopy. None have developed cancer while being followed. We have seen many who developed dysplasia on follow-up endoscopies. None have progressed to cancer. The time to worry is when you have a bag over your head, with a see no evil, hear no evil mentality.
Coming back to Jim, we learned by using High Definition endoscopy with Narrow Band Imaging that the apparently flat mucosa was in fact a raised bump. This level of expertise and technology is critical in protecting patients from undiagnosed dysplasia. The biopsies showed focal high grade dysplasia. Dysplasia is classified in five grades. No dysplasia, indeterminate dysplasia, low grade dysplasia, high grade dysplasia, and invasive cancer. These are the same as in a Pap smear of the cervix that the gynecologist utilizes. The indeterminate category implies a great deal of inflammation that needs to be treated before the pathologist can be sure. So many times I see on the first endoscopy a lot of inflammation and erosions and the Barrett’s can not be determined until all of that has healed with treatment. When we see indeterminate dysplasia, we intensify the treatment and then rescope after 3 months with additional biopsies.By: Kevin Dooley