Barrett esophagus

The importance of an in-depth understanding about Barrett esophagus is ultimately to decrease the mortality and morbidity from esophageal adenocarcinoma cancer by early detection of metaplasia and dysplasia and appropriate therapy. This review summarizes several publications in the past year related to the epidemiology, pathogenesis, screening and surveillance, new methods for detection of metaplasia/dysplasia, and advances in the treatment of Barrett esophagus.

Patients with Barrett esophagus are characterized by the presence of risk factors usually indicative of severe types of gastroesophageal reflux disease. Recent insights into epidemiology and pathogenesis have shown that the risk of high-grade dysplasia and adenocarcinoma may be related to the increasing length of Barrett esophagus, size of hiatus hernia, and severity of acid reflux. The role of smoking and alcohol consumption remains controversial. Increasing the number of biopsies by repeat standard endoscopy can enhance the yield of intestinal metaplasia in patients with suspected short-segment Barrett esophagus. Costs of surveillance using standard endoscopy and random biopsies would be very high and using special techniques to target specific areas could ultimately help in cost reduction. Emerging data on new techniques and technology such as vital staining with methylene blue and protoporphyrin fluorescence can increase the yield of metaplasia and dysplasia. Biomarkers studies have revealed that p53 mutation by the loss of heterozygosity can help detect patients with low and high risk for cancer progression. Studies thus far have been unclear whether acid suppression alone can impact the malignant progression in Barrett esophagus patients. Inhibition of cyclooxygenase by aspirin or nonsteroidal anti-inflammatory drugs may be a promising chemoprevention strategy against dysplasia and esophageal adenocarcinoma development as shown in some recent studies. Nonsurgical treatment by photodynamic therapy or mucosal resection may be a less invasive and organ-sparing option for some patients with high-grade dysplasia and early adenocarcinoma.

In the past year we have made major strides in our knowledge of this premalignant lesion. Recent studies have shed light in a better understanding of the epidemiology of Barrett esophagus, including clinical and endoscopic factors associated with high-grade dysplasia or esophageal adenocarcinoma and various biomarkers that would identify patient subsets with low and high risk for cancer progression. This will eventually have significant implications on the screening, surveillance, and treatment of the disease. Advanced endoscopic therapies including mucosectomy or photodynamic therapy may be emerging options in patients with intraepithelial neoplasia.