Journal of Gastroenterology & Endoscopy

Reviewing Barrett’s Esophagus 

Hazim Abdul Rahman Alhiti^1,2

¹Head of Emergency Faculty, Higher Health Institute, Al Anbar Directorate, Hit, Iraq
²General Surgeon Specialist MD-Academic Lecturer, Al-Ramadi Teaching Hospital, Iraq

Corresponding author
Hazim Abdul Rahman Alhiti, Head of Emergency Faculty, Higher Health Institute, Al Anbar Directorate, Hit, Iraq.

ABSTRACT
Introduction: Barrett’s esophagus is a common condition with serious complictions.

Objective: This is a review of Barrett’s esophagus as it is an important topic. 

Method: This is a review of papers on Europe PMC (https://europepmc.org/) as a trusted academic engine concerning Barrett’s Esophagus. The search included a specific keyword (Barrett’s) then (AND) then specific related keywords. Papers from the last five years were preferred, with no exclusion. Excel 2010 was utilized for data management.

Results: From 13,542 studies concerning (Barrett’s) on the previously mentioned search, 2,402 papers (17.7 %) were in Case reports, 6,067 articles (44.8 %) were in Reviews, 1,993 studies (14.7 %) were in Clinical trials, and 3,080 papers (22.7 %) were in Miscellaneous. The author organizes the diagnostic tests, medical, and surgical treatments of Barrett’s Esophagus to facilitate easy remembering.

Conclusions: Barrett’s esophagus is a serious gastrointestinal disorder that can increase the risk of developing esophageal cancer. Suspicion of diagnosis is crucial and the treatment strategies for Barrett’s esophagus aim to alleviate symptoms, control GERD, and reduce the risk of cancer.

Keywords: Review, Barrett’s Esophagus, Esophagitis, Europe PMC, Esophageal Cancer

Introduction
Barrett’s esophagus is a condition where the lining of the lower esophagus is damaged by stomach acid and becomes replaced by tissue that is similar to the lining of the intestine, which increases the possibility of esophageal cancer. It is often associated with chronic gastroesophageal reflux disease (GERD), with a prevalence estimated between 1-5% of the general population. It is common in adult men as it increases with age. It is also more commonly found in those who have had long-term or severe GERD, as well as those with a family history of the condition [1].

The incidence of Barrett’s esophagus is also higher in those who smoke, are obese, and consume alcohol regularly. However, not everyone with GERD will develop Barrett’s esophagus, and the condition can occur in individuals without GERD as well. 

The precise epidemiology of Barrett’s esophagus is not well established, but some studies suggest that the prevalence of Barrett’s esophagus is increasing over time. The condition is also more common in individuals over the age of 50, and the incidence increases with age. 

Several studies have suggested that the incidence of esophageal adenocarcinoma, a potentially lethal complication of Barrett’s esophagus, has been increasing over time in the Western world, likely due to the rising incidence of GERD and obesity. However, the overall incidence of esophageal adenocarcinoma in individuals with Barrett’s esophagus is relatively low [2].

The exact pathophysiology of Barrett’s esophagus is not fully understood, but it is thought to be associated with long-term gastroesophageal reflux disease (GERD) and chronic inflammation of the lower esophagus. The reflux of stomach acid and bile into the lower esophagus causes chronic irritation and inflammation, leading to changes in the cellular makeup of the esophageal lining. This process is thought to be mediated by a combination of genetic factors, environmental factors, and cellular signaling pathways. The changes in the cellular makeup of the esophageal lining in Barrett’s esophagus increase the risk of developing esophageal cancer, particularly adenocarcinoma [3].

This is a review of Barrett’s esophagus as it is an important topic. 

Methods
This is a review of papers on Europe PMC (https://europepmc.org/) as a trusted academic engine concerning Barrett’s Esophagus. The search included a specific keyword (Barrett’s) then (AND) then specific related keywords. Papers from the last five years were preferred, with no exclusion. Excel 2010 was utilized for data management.

Results
From 13,542 studies concerning (Barrett’s) on the previously mentioned search, 2,402 papers (17.7 %) were in Case reports, 6,067 articles (44.8 %) were in Reviews, 1,993 studies (14.7 %) were in Clinical trials, and 3,080 papers (22.7 %) were in Miscellaneous. The author organizes the diagnostic tests, medical, and surgical treatments of Barrett’s Esophagus to facilitate easy remembering.

Discussion
The author chooses Barrett’s esophagus as it is an important topic. It is a condition in which the normal lining of the esophagus is replaced by abnormal cells. It is considered significant because it is a risk factor for developing esophageal adenocarcinoma (a type of cancer). Individuals with Barrett’s esophagus are at an increased risk of developing esophageal adenocarcinoma, which is a type of cancer that can be difficult to treat and has a poor prognosis [4].

The author chooses Europe PMC (PubMed Central) as it is a free online database that provides access to scientific literature in the fields of life sciences and biomedical research. Europe PMC offers a comprehensive collection of research articles, as well as other types of content, including patents, clinical guidelines, and preprints. Moreover, it is integrated with other databases like ORCID, Scopus, CrossRef, and DataCite, making it possible to build meaningful connections between scientific literature and related scientific data [5].

From Table 1 and Figure 1, the reader might notice the huge number of research studies on the word (Barrett’s), which indicates the importance of this topic. The economic effects of Barrett’s esophagus can be significant. The cost of medical care for this condition can be high, especially if the patient requires frequent visits to the doctor and/or specialist care. Furthermore, the condition could affect the patient’s quality of life, leading to mental health issues such as depression or anxiety, which could further exacerbate the economic impacts. The economic effects of Barrett’s esophagus can be significant, depending on the severity of the condition and the patient’s ability to manage their symptoms and adhere to their treatment plan [6-8].

From 13,542 studies concerning (Barrett’s) on the previously mentioned search, 2,402 papers (17.7 %) were in Case reports, which signifies the desire of the scientists to present their patients who complained of Barrett’s esophagus. Moreover, 6,067 articles (44.8 %) were in Reviews. This large number of studies indicates the intent of the physician to summarize the problem depending on previous studies. There were 1,993 studies (14.7 %) in Clinical trials. These trials focused on the usage of new drugs/procedures or a comparison of the new/old remedies or techniques. Those researchers applied ethical and stepwise methods to verify their results. Still, 3,080 papers (22.7 %) were in miscellaneous articles to present their ways of introducing this significant topic [9].

Barrett’s esophagus usually caused by acid reflux and can increase the risk of developing esophageal cancer. Frequent and prolonged heartburn or acid reflux, difficulty swallowing, chest pain, nausea and vomiting, regurgitation of food, even for liquids, hoarseness or sore throat, chronic cough, belching. Early diagnosis and treatment can help manage the symptoms and reduce the risk of developing esophageal cancer [10].

A Complete Blood Count with Differential (CBC with Diff) is a blood test that measures various components of the blood, including red blood cells, white blood cells, and platelets. Although Barrett’s esophagus is not typically associated with changes in the CBC with Diff, there are several reasons why this blood test might be ordered as part of the diagnostic workup or monitoring of a patient with this condition [11].

A patient with Barrett’s esophagus develops anemia (low red blood cell count), then CBC with Diff can help determine the cause. The patient with Barrett’s esophagus might has an infection (such as fever or leukocytosis), or to monitor blood counts after chemotherapy, then CBC with Diff can help monitor potential side effects [12].

Helicobacter pylori (H. pylori) is a type of bacteria that is commonly associated with peptic ulcer disease and gastritis, some studies have suggested that eradication of H. pylori in patients with Barrett’s esophagus may help reduce the risk of progression to esophageal cancer. The most accurate method to detect it is by a biopsy of the stomach lining obtained during an upper endoscopy procedure, which can detect the presence of H. pylori bacteria in the stomach. [13,14].

Tumor markers are not specific tumor markers that are routinely used in the diagnosis or management of Barrett’s esophagus, some studies have examined the use of certain markers in this condition, particularly in the context of progression to esophageal cancer. One marker that has been studied is p53, a tumor suppressor gene that is commonly mutated in esophageal cancer. Studies have suggested that mutations in the p53 gene are more common in patients with Barrett’s esophagus who progress to esophageal cancer than in those who do not progress, and testing for p53 mutations may help identify patients at higher risk for cancer. Similarly, overexpression of a protein called HER-2/neu has been reported in some cases of esophageal adenocarcinoma, and some studies have suggested that testing for HER-2/neu overexpression may help identify patients who are more likely to respond to certain targeted therapies [15].

Oesophago Gastro Duodenoscopy (OGD) is an important tool in the diagnosis and management of Barrett’s esophagus. OGD can detect Barrett’s esophagus in its early stages before it progresses to cancer. Regular surveillance with OGD can also help detect early signs of cancer, leading to timely intervention and improved outcomes. During an OGD, tissue samples can be taken from the esophagus for biopsy and examination under a microscope [16,17].

Barium swallow, and a barium meal, is also be useful in certain situations. Barium swallow is a non-invasive test that can help diagnose Barrett’s esophagus. It can detect changes in the shape and structure of the esophagus caused by the abnormal cell growth in the lining. Barium swallow can help detect complications of Barrett’s esophagus, such as strictures, which can cause difficulty in swallowing [18].

Esophageal manometry is a diagnostic test that help assess the function of the lower esophageal sphincter (LES) that controls the flow of food and acid from the esophagus into the stomach. It help diagnose complications of Barrett’s esophagus such as achalasia and scleroderma [19].

An esophageal biopsy is crucial in the diagnosis and management of the condition. Biopsy is the gold standard for the diagnosis of Barrett’s esophagus. Regular biopsies can detect any changes in the tissue and catch early signs of precancerous cells or cancer cells. [20].

Proton pump inhibitors (PPIs) are commonly used to treat Barrett’s esophagus, because they reduce the amount of acid in the stomach, which can help prevent further damage to the lining of the esophagus [21].

Anti-motility drugs are commonly used to treat certain gastrointestinal conditions. While anti-motility drugs may help alleviate symptoms of acid reflux, such as heartburn and indigestion, they do not address the underlying cause of Barrett’s esophagus [22].

Screening endoscopy is recommended for individuals who are at high risk of developing Barrett’s esophagus, such as those with chronic acid reflux or a family history of the condition. Early detection of Barrett’s esophagus through screening endoscopy can allow for prompt treatment and management of the condition before it develops into esophageal cancer [23].

There are several general can help reduce symptoms, prevent complications, and support overall health. Certain lifestyle changes can help reduce symptoms and improve overall health. These changes may include losing weight if needed, quitting smoking, avoiding trigger foods that can cause acid reflux, and eating smaller, more frequent meals. Medications such as proton pump inhibitors (PPIs) can help reduce acid reflux and inflammation in the esophagus. These medications are often the first-line treatment for Barrett’s esophagus. Regular endoscopic surveillance is recommended for individuals with Barrett’s esophagus to monitor for any changes in the esophageal lining and detect early signs of cancer depends on the severity of the condition [24,25].

Psychotherapy can play an important role in the management of Barrett’s esophagus, it can provide significant benefits in terms of emotional well-being and coping with the challenges associated with the condition. Barrett’s esophagus include techniques such as relaxation exercises, breathing techniques, and cognitive-behavioral therapy (CBT) interventions. Psychotherapy can assist individuals in developing adaptive coping strategies to deal with the challenges of living with Barrett’s esophagus. This may involve exploring and modifying unhelpful thought patterns, learning problem-solving skills, and developing resilience. Psychotherapy can addressing issues related to diet and lifestyle, creating a self-care routine, and identifying activities that bring joy and fulfillment [26].

Photodynamic therapy (PDT) is a minimally invasive procedure used to treat Barrett’s esophagus, PDT has been shown to be an effective treatment option for Barrett’s esophagus, with studies reporting a significant reduction in the risk of esophageal cancer following PDT. PDT is particularly beneficial for patients who are not eligible for these procedures or for those who prefer a less invasive option [27].

Endoscopic mucosal resection (EMR) is an important treatment option for patients with Barrett’s esophagus as it allows for the removal of precancerous or early stage cancerous lesions. Studies have shown that EMR can achieve high rates of complete remission for early-stage cancerous lesions in Barrett’s esophagus [28].

Cryotherapy is an important treatment option for patients with Barrett’s esophagus as it can effectively ablate precancerous or early-stage cancerous lesions and prevent the progression of the disease to esophageal cancer. The significance of Cryotherapy in Barrett’s esophagus lies in its ability to selectively target and destroy diseased tissue while leaving healthy tissue intact. The combination of Cryotherapy and PDT has been shown to be particularly effective in treating high-grade dysplasia and early-stage esophageal cancer [29].
Endoscopic Submucosal Dissection (ESD) is an important treatment option as it allows for the removal of larger, more complex lesions, and can help prevent the development of invasive esophageal cancer. ESD is particularly useful for treating larger or multifocal lesions that are too extensive for other less invasive procedures like endoscopic mucosal resection (EMR), which may involve removing lesions in smaller segments. ESD can also be used to remove lesions that are located in challenging locations, such as the upper and lower parts of the esophagus or at the junction with the stomach. [30].

Radiofrequency Ablation (RFA) is particularly effective in treating high-grade dysplasia, which is a precancerous condition that increases the risk of developing esophageal cancer. It is usually performed on an outpatient basis, and patients can typically resume their normal activities within a short time. Moreover, RFA can reduce the frequency of endoscopies required for patients to monitor the condition of their Barrett’s esophagus, and patients can typically undergo follow-up endoscopy at more extended intervals [31].

Oesophagectomy is not commonly performed unless the condition has progressed to a stage where there is dysplasia or cancer development. Early-stage esophageal cancer that is confined to the superficial layers of the esophagus can be treated effectively with an oesophagectomy. In patients with high-grade dysplasia or intramucosal carcinoma (cancer that has not penetrated through the lining of the esophagus), oesophagectomy may be recommended to prevent the progression of the cancer and improve survival rates. Therefore, it is typically reserved for cases where there is a high risk of cancer progression and alternative treatment options are not viable [32]. 

The importance of Nissen fundoplication in Barrett’s esophagus lies in the fact that GERD is a major risk factor for developing Barrett’s esophagus and worsening of the condition. Additionally, some studies have suggested that Nissen fundoplication may even improve the histological appearance of Barrett’s esophagus. In the context of Barrett’s esophagus, the importance of the LINX device lies in its potential to reduce the symptoms of GERD, which can reduce the risk of developing and worsening of Barrett’s esophagus. The LINX device can provide significant symptom relief for patients with GERD by restoring the normal function of the lower esophageal sphincter, which can reduce the frequency and severity of acid reflux. The LINX device can be removed or adjusted if necessary, making it a more flexible treatment option compared to other surgical procedures [33].

Life-saving procedures such as emergency endoscopy, emergency surgery, and blood transfusions may be necessary in rare cases of Barrett’s esophagus. These procedures are important in preventing life-threatening complications and improving survival rates for patients who experience severe bleeding, obstructive symptoms or cancer development. Severe bleeding from the esophagus is a potentially life-threatening complication of Barrett’s esophagus. Emergency endoscopy can be used to identify the cause of bleeding and stop it using techniques such as endoscopic band ligation or sclerotherapy. Blood transfusions may also be necessary to replace blood loss. Obstructive symptoms can also occur in advanced stages of Barrett’s esophagus, particularly if cancer has developed. Emergency surgery may be required to remove the obstructed portion of the esophagus and provide relief of symptoms [34,35].

Conclusions
Barrett’s esophagus is a serious gastrointestinal disorder that can increase the risk of developing esophageal cancer. Suspicion of diagnosis is crucial and the treatment strategies for Barrett’s esophagus aim to alleviate symptoms, control GERD, and reduce the risk of cancer. 

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