Barrett’s esophagus is a condition in which the normal lining of the lower esophagus changes. The flat, pale squamous cells that usually line the esophagus are gradually replaced by columnar cells that resemble the lining of the intestine, a process called intestinal metaplasia. This change is the body’s response to repeated injury from stomach acid, and it develops in some people who have had long-standing gastroesophageal reflux disease (GERD).
Barrett’s esophagus matters because it is the main known risk factor for a type of esophageal cancer called esophageal adenocarcinoma. However, the absolute risk is low, and most people with Barrett’s esophagus never develop cancer. Around 5% of adults are estimated to have Barrett’s esophagus, and it is roughly two to three times more common in men than in women.
Dysplasia refers to precancerous changes within the Barrett’s tissue, meaning the cells look abnormal under the microscope but have not become cancer. It is graded by how abnormal the cells appear:
- No dysplasia: the Barrett’s tissue is present but the cells are not precancerous
- Low-grade dysplasia: early, mild precancerous changes
- High-grade dysplasia: more marked precancerous changes, carrying the highest risk of progressing to cancer
There is also an “indefinite for dysplasia” category used when inflammation makes the cells difficult to assess. Barrett’s esophagus tends to progress in a stepwise way: metaplasia, then low-grade dysplasia, then high-grade dysplasia, and finally cancer, although most people never move along this path.
Barrett’s esophagus itself does not cause any symptoms. Any symptoms a person notices come from the underlying acid reflux, and may include:
- Frequent heartburn
- Regurgitation of stomach contents
- Difficulty swallowing food
- Less commonly, chest pain
Importantly, about half of people diagnosed with Barrett’s esophagus report little or no reflux symptoms, sometimes called “silent reflux.” Because the condition is symptomless on its own, it is often discovered during an endoscopy performed for other reasons.
Causes and Risk Factors
Barrett’s esophagus is caused by chronic reflux of stomach acid, and sometimes bile, which repeatedly damages the lining of the lower esophagus. The exact mechanism by which this triggers the tissue change is not fully understood. Most people who develop Barrett’s esophagus have had reflux for many years.
Recognised risk factors include:
- Chronic, long-standing or frequent GERD
- Age, with the condition becoming more common from around age 50
- Male sex
- White ethnicity
- Excess weight around the waist (central obesity)
- Current or past smoking
- A family history of Barrett’s esophagus or esophageal cancer
- A hiatal hernia
Between 10% and 15% of people with GERD are found to have Barrett’s esophagus.
Diagnosis
Barrett’s esophagus is diagnosed with upper endoscopy (gastroscopy) combined with biopsy. During the procedure, a thin flexible camera examines the esophagus. Normal esophageal lining looks pale and smooth, whereas Barrett’s tissue appears salmon-coloured. Small tissue samples (biopsies) are taken and examined under the microscope to confirm intestinal metaplasia, since the visual appearance alone is not enough for diagnosis.
The extent of Barrett’s tissue is recorded using the standardised Prague C&M classification, which measures the circumferential and maximal length of the affected segment. Short-segment Barrett’s is defined as less than 3 cm and long-segment as 3 cm or more. During surveillance, doctors follow a systematic biopsy approach (the Seattle protocol), taking samples at set intervals and from any visible abnormality.
Because grading dysplasia can be difficult and open to interpretation, any diagnosis of dysplasia should be confirmed by a second pathologist, ideally one who specialises in gastrointestinal pathology.
Cancer Risk and Progression
Barrett’s esophagus is the main risk factor for esophageal adenocarcinoma, but the yearly risk of progression is low. For Barrett’s esophagus without dysplasia, the risk of developing cancer is approximately 0.3% to 0.5% per year, often summarised as about half a percent per year. The risk increases with the degree of dysplasia: low-grade dysplasia carries a somewhat higher annual risk, while high-grade dysplasia carries a substantially higher risk of progression.
Estimates vary between studies, and it is important to remember that the overwhelming majority of people with non-dysplastic Barrett’s esophagus never develop cancer. The purpose of monitoring is to catch any changes early, when they can be treated effectively.
Treatment and Management
Treatment depends on whether dysplasia is present and, if so, its grade. The general framework is:
- No dysplasia: regular surveillance endoscopy, typically every 3 to 5 years; ablation is not routinely recommended because the progression risk is low
- Indefinite for dysplasia: acid suppression is optimised for a few months and the endoscopy is repeated; if dysplasia is then confirmed, closer follow-up is arranged
- Low-grade dysplasia (confirmed): endoscopic eradication therapy is the preferred treatment, though surveillance every 12 months is an acceptable alternative
- High-grade dysplasia (confirmed): endoscopic treatment is recommended
- Very early cancer confined to the surface layer :endoscopic treatment is the preferred approach
Medication
Once-daily proton pump inhibitor (PPI) therapy is recommended for people with Barrett’s esophagus to control reflux and heal the esophagus. Twice-daily dosing is used only when reflux or inflammation is not well controlled. Aspirin and other anti-inflammatory medicines are not routinely recommended purely as a cancer-prevention strategy.
Endoscopic Treatments
When dysplasia or very early cancer is present, it can often be treated during endoscopy, without the need for major surgery:
- Endoscopic mucosal resection (EMR): visible or raised lesions are removed and sent for analysis, which also guides further treatment
- Radiofrequency ablation (RFA): the preferred method for treating flat areas of dysplastic Barrett’s tissue by destroying it with controlled heat energy
- Other techniques such as cryotherapy may also be used
Surgery (esophagectomy) is reserved for extensive high-grade disease, cancer that has grown deeper into the esophageal wall, or when complications occur. Anti-reflux surgery may be considered when reflux cannot be controlled with medication, but it is not performed purely to prevent cancer.
After successful eradication of Barrett’s tissue, continued surveillance is important because the condition can recur.
Prognosis
Most people with Barrett’s esophagus never develop esophageal cancer, and the risk remains small even when precancerous changes are present. People with non-dysplastic Barrett’s esophagus can live normally, provided the condition is monitored and the underlying reflux is controlled. The metaplastic tissue does not resolve on its own, but it can be removed endoscopically when needed. Because Barrett’s esophagus can return after treatment, ongoing follow-up is advised. Detecting and treating dysplasia early leads to a better outlook.
When to See a Doctor
Anyone who has had heartburn, regurgitation or acid reflux for more than five years should talk to a doctor about their risk of Barrett’s esophagus. Seek prompt medical attention for any of the following alarm symptoms:
- Difficulty swallowing (dysphagia)
- Vomiting blood or material that looks like coffee grounds
- Black, tarry or bloody stools
- Unintentional weight loss
- Chest pain
Early diagnosis and appropriate monitoring are the most effective ways to manage Barrett’s esophagus and reduce the risk of serious complications.