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Barrett Esophagus

Barrett Esophagus is a topic covered in the 5-Minute Clinical Consult.

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Basics

Description

  • Metaplasia of the distal esophageal mucosa from native stratified squamous epithelium to abnormal columnar (intestinalized) epithelium, likely as a consequence of chronic GERD
  • Predisposes to the development of adenocarcinoma of the esophagus

Epidemiology

  • Predominant age: >50 years
  • May occur in children (rare <5 years)

Incidence
  • 10–15% of patients undergoing endoscopy for evaluation of reflux symptoms
  • Esophageal adenocarcinoma incidence is rising in the United States (1). From 1975 to 2001, there was ~6-fold increase, from 4 to 23 cases/million person-years.
  • Attributed to changes in smoking and obesity rather than reclassification or overdiagnosis
Prevalence
  • Difficult to ascertain because of different populations studied, varying definitions, and asymptomatic cases
  • As many as 1.5 to 2.0 million adults in the United States (extrapolated from a 1.6% prevalence in Swedish general population)

Etiology and Pathophysiology

  • Chronic gastric reflux injures the esophageal mucosa, triggering columnar metaplasia. Refluxed bile acids likely induce differentiation in gastroesophageal junction (GEJ) cells.
  • Columnar cells in the esophagus have higher malignant potential than squamous cells. Activation of CDX2 gene and overexpression of HER2/neu (ERBB2) oncogene promotes carcinogenesis.
  • Elevated levels of COX-2, a mediator of inflammation and regulator of epithelial cell growth, are associated with Barrett esophagus (BE) (1).
  • Classic progression: normal epithelium → esophagitis → metaplasia (BE) → dysplasia (low- or high-grade) → adenocarcinoma

Genetics
  • Familial predisposition to GERD and BE with multiple genetic markers have been identified.
  • Acquired genetic changes lead to adenocarcinoma and are being investigated as biomarkers for risk stratification and early detection.

Risk Factors

  • Chronic reflux (>5 years)
  • Hiatal hernia
  • Age >50 years
  • Male gender
  • White ethnicity—incidence in white males is much higher than white women and African American men.
  • Smoking history
  • Intra-abdominal obesity
  • Family history—at least one first-degree relative with BE or esophageal adenocarcinoma

General Prevention

Weight loss, smoking cessation, robust intake of fruits and vegetables, and moderate wine consumption may decrease risk of BE and lower progression to esophageal cancer (1)[C].

Commonly Associated Conditions

GERD, obesity, hiatal hernia

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Citation

Stephens, Mark B., et al., editors. "Barrett Esophagus." 5-Minute Clinical Consult, 27th ed., Wolters Kluwer, 2019. Medicine Central, im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/816491/all/Barrett_Esophagus.
Barrett Esophagus. In: Stephens MB, Golding J, Baldor RA, et al, eds. 5-Minute Clinical Consult. 27th ed. Wolters Kluwer; 2019. https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/816491/all/Barrett_Esophagus. Accessed April 24, 2019.
Barrett Esophagus. (2019). In Stephens, M. B., Golding, J., Baldor, R. A., & Domino, F. J. (Eds.), 5-Minute Clinical Consult. Available from https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/816491/all/Barrett_Esophagus
Barrett Esophagus [Internet]. In: Stephens MB, Golding J, Baldor RA, Domino FJ, editors. 5-Minute Clinical Consult. Wolters Kluwer; 2019. [cited 2019 April 24]. Available from: https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/816491/all/Barrett_Esophagus.
* Article titles in AMA citation format should be in sentence-case
TY - ELEC T1 - Barrett Esophagus ID - 816491 ED - Stephens,Mark B, ED - Golding,Jeremy, ED - Baldor,Robert A, ED - Domino,Frank J, BT - 5-Minute Clinical Consult, Updating UR - https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/816491/all/Barrett_Esophagus PB - Wolters Kluwer ET - 27 DB - Medicine Central DP - Unbound Medicine ER -