Rita Knotts, MD, on Barrett Esophagus

In this podcast, Dr Knotts, Section Editor for Esophageal Diseases and Disorders on Gastroenterology Learning Network, discusses the risk factors for Barrett esophagus, how it relates to the risk of esophageal cancer, who should be screened, and the screening methods available.

Discover more insights from your peers in our Esophageal Diseases and Disorders Excellence Forum.

Rita Knotts, MD, is a gastroenterologist specializing in neurogastroenterology, motility disorders, and conditions affecting the esophagus at NYU-Langone Health's Center for Esophageal Health in New York City.

Transcript: 

Hello everyone, and welcome to another podcast from the Gastroenterology Learning Network. I’m managing editor Rebecca Mashaw. Today we will hear from Dr Rita Knotts from NYU-Langone Health on Barrett esophagus, including the actual risk of the condition, who should be screened, and the types of screening available today as well as those coming up in the near future.

Dr. Rita Knotts:  Hi, I’m Rita Knotts from NYU Langone Health, the Center for Esophageal Health, and today, I'm going to talk to you about Barrett's esophagus. We typically think of Barrett's esophagus as a condition that's caused by reflux.

Yes, reflux is a risk factor for Barrett's. Barrett's has been detected in about 15% of patients with chronic reflux, but in about 1% to 2% of the general population. The risk of progression for patients with Barrett's esophagus or nondysplastic Barrett's esophagus is actually pretty low. It's about .2% to .5% per year.

This risk goes up with varying degrees of dysplasia. Patients with low-grade dysplasia have an annual risk of progression that's about .7% per year, and high-grade dysplasia has an annual risk of progression to esophageal adenocarcinoma of about 7% per year.

Let's be clear here. The majority of patients aren't going to die from Barrett's esophagus. The number one cause of mortality is the same as for all other Americans, which is cardiac disease. A majority of patients are going to die from other causes other than esophageal adenocarcinoma.

Patients with Barrett's esophagus don't always present with chronic reflux, but severe and chronic GERD are risk factors for esophageal adenocarcinoma. About 40% of patients diagnosed with esophageal cancer actually report no history of prior GERD symptoms.

This may be due to a relative esophageal hyposensitivity among patients with Barrett's esophagus, because there's been some splicing of some evidence suggesting that there's a relative decrease in esophageal sensitivity to stimuli among these patients.

When we balance the relative rarity of Barrett's esophagus, and the even greater rarity of adenocarcinoma, how do we decide who actually gets screening? Current guidelines actually suggest that screening for Barrett's esophagus should be considered in men with chronic or frequent reflux symptoms. That's greater than 5 years of symptoms or weekly or more symptoms and 2 or more risk factors for Barrett's esophagus or esophageal adenocarcinoma. These risk factors include an age greater than 50, Caucasian race, central obesity that's based on waist circumference or waist-to-hip ratio of greater than .9, a current or ever past history of smoking, having a family history of Barrett's esophagus, or esophageal carcinoma in a first-degree relative.

Now, women typically are not screened unless they also have multiple risk factors. Similarly, advanced age greater than 50, Caucasian race or frequent GERD symptoms, and central obesity or smoking history, or family history.

We don't screen the general population here. It's also important to note that, if you do an upper endoscopy on a patient with reflux, and you find esophagitis — and that's grade B or higher — you always want to repeat the upper endoscopy in about 8 to 12 weeks to ensure for healing, but also to exclude underlying Barrett's esophagus. I've honestly found high-grade dysplasia and even adenocarcinoma after esophagitis has healed. It's not enough just to put patients on a PPI. You really need to come back and screen them again.

Typically, our gold standard for screening is an upper endoscopy or esophageal gastroduodenoscopy. It's pretty expensive and invasive, but it is the best technique that we currently have. There is also unsedated transnasal endoscopy that can be considered as an alternative to conventional upper endoscopy for Barrett's screening, but it's not widely available.

There are also newer tools that are also not widely available yet, but hopefully become mainstream, or can become mainstream in the future. This includes the cytosponge, which is a novel device. It basically consists of an ingestible gelatin capsule on a string. Once that device makes its way down to the stomach, the capsule dissolves that small sponge. Then it can be withdrawn through the esophagus, through the mouth by pulling on that string. During this process, the sponge is actually able to collect esophageal cells that can be used for screening.

It can be used for looking for Barrett's esophagus, dysplasia, and also adenocarcinoma. Once the cells are ultimately collected, they're tested for trefoil factor 3, which is a biomarker for Barrett's esophagus. It's this biomarker that helps distinguish Barrett's esophagus from gastric cells and squamous cells within the esophagus.

There's also volumetric laser endomicroscopy, which again, is not yet mainstream, but that's also a tethered capsule that's attached to a laptop computer. The patient swallows that capsule, and then you can move that capsule back and forth to look at the GE junction in the esophagus.

Also not yet widely available are balloons that are attached and tethered to the catheter that can be pulled back and forth at the GE junction to assess for Barrett's cells. When we find Barrett's esophagus in a patient, it really depends on what changes you find on your initial endoscopy.

We don't recommend rescreening if you don't find Barrett's esophagus initially, but surveillance endoscopy is recommended every 3 to 5 years for patients with Barrett's esophagus without dysplasia. Endoscopic surveillance should employ 4-quadrant biopsies at 2-centimeter intervals in patients with and without dysplasia and in 1-centimeter intervals in patients with prior dysplasia.

If high-grade dysplasia or cancer is observed, of course, patients need to undergo treatment to prevent invasive adenocarcinoma. For endoscopic treatment, clinicians first use endoscopic resection to remove abnormal raised or nodular areas. Then the remainder of the flat Barrett's esophagus is then ablated using radiofrequency ablation, either argon plasma coagulation or cryotherapy, but surveillance should really be every 6 to 12 months with low-grade dysplasia, and every 3 months for those with high-grade dysplasia if it's not eradicated.

In the future, I hope to see better noninvasive means of testing and screening. We need to prioritize the population that needs screening. As we discussed before, there's a lot of patients that don't have GERD symptoms.

As a society, guidelines — all society guidelines — currently recommend against screening for the general population and propose targeted screening. I think we need to get better here to help risk-stratify patients.

I think that, in patients with known Barrett's esophagus, a variety of medications have also been associated with a reduced risk of progression to dysplasia and cancer. That includes PPIs, aspirin, NSAID, statins.

I think we need to further study this and assess how these things can fit into our current guidelines for chemo prevention. I think that there is a lot of work that needs to be done for noninvasive testing, and there is a lot trials that currently still underway.

Even though endoscopy with biopsy is our gold standard, we need to really get better to allow this to be more widely available to the public and to help target our biopsies, help target our patient population to enhance care. Thank you so much for listening today.