Barrett's oesophagus: reflux, surveillance and treatment

The oesophagus, or gullet, carries food to the stomach. In Barrett's oesophagus, Guts UK explains, normal cells lining the gullet are replaced by abnormal-looking cells that start where the oesophagus and stomach meet and spread upwards. The change is called intestinal metaplasia because the lining comes to resemble that of the bowel.

Guts UK says it is possible for Barrett's oesophagus to lead to cancer, but this happens in a few people and most will not develop cancer. That balance, a small absolute risk that is nonetheless higher than average, shapes the whole approach to care.

Guts UK says the exact cause is unknown but it is strongly linked to long-term gastro-oesophageal reflux disease, in which acid and non-acid stomach juices leak into the oesophagus and injure its lining. The risk rises with the length of time people have symptoms and with how often they occur.

• Older age.

• Being male; it is more common in white men.

• A family history of Barrett's oesophagus.

• A higher than healthy body weight.

• Smoking.

• A hiatus hernia, where the stomach extends from the abdomen into the chest.

Guts UK says the main symptom is reflux: heartburn, bringing food back up (regurgitation), sometimes a metallic taste or sore throat, often worse when lying down. Waking at night with reflux symptoms is described as a strong risk factor. Some people report no symptoms because the oesophagus is less sensitive to reflux, and the charity warns that ignoring symptoms or self-medicating with antacids can delay diagnosis.

Guts UK explains that doctors diagnose Barrett's by looking at the lining with an endoscopy, a thin tube with a camera passed through the mouth, which can be done with local anaesthetic spray and sedation. Barrett's tissue looks red compared with the normal pink lining, and biopsies confirm the diagnosis; a pathologist also looks for dysplasia, graded low or high. The endoscopist describes the extent using the Prague classification, where C is the circumferential length and M the maximum length.

The charity also describes a capsule sponge test, available in some areas of the UK for people with persistent heartburn and reflux: you swallow a capsule on a thread, the sponge collects cells as it is pulled back and the cells are checked in the laboratory; a positive result leads to an endoscopy. Transnasal endoscopy, using a thinner instrument through the nose, is available in some centres.

NICE guideline NG231 says to offer a clinical consultation after a new diagnosis to discuss cancer risk, surveillance plans and symptom control, and to give verbal and written information. It recommends high-resolution white light endoscopy with Seattle protocol biopsies, with the frequency tailored to age, sex, family history of oesophageal cancer and smoking history within the intervals below.

Guts UK says the commonest medicines are proton pump inhibitors such as omeprazole and lansoprazole, which reduce acid production, and that people diagnosed with Barrett's should continue medical treatment; alternatives such as famotidine are less effective, especially in the long term. Lifestyle measures aimed at reducing reflux include weight loss, drinking less alcohol, stopping smoking, smaller portions and not eating within three hours of bedtime. If medicines and lifestyle changes do not help, a laparoscopic Nissen fundoplication is an option. The charity notes that these treatments do not remove Barrett's oesophagus or eliminate the small cancer risk.

NICE says not to offer aspirin to people with Barrett's oesophagus to prevent progression to dysplasia and cancer, and refers prescribers to its GORD guideline for reflux treatment.

Guts UK says the management of high-grade dysplasia and early cancer has changed: instead of close monitoring until cancer appeared or major surgery to remove the oesophagus, minimally invasive endoscopic therapy at specialist centres now treats the affected lining. Endoscopic mucosal resection (EMR) removes small areas of abnormality and also gives more information than a biopsy; the charity quotes a risk of bleeding of approximately 1 in 50 and perforation of about 1 in 200 procedures. Radiofrequency ablation burns away abnormal cells.

NICE recommends endoscopic resection of visible lesions, endoscopic ablation of any residual Barrett's after resection in high-grade dysplasia, and radiofrequency ablation for low-grade dysplasia diagnosed from biopsies at 2 separate endoscopies. If low-grade dysplasia is found, Guts UK says a repeat endoscopy in 6 months is ordered, and people with high-grade dysplasia are referred quickly to a specialist centre.

Guts UK lists trouble swallowing, frequent regurgitation or vomiting after eating or drinking, pain on swallowing, weight loss, anaemia, vomiting blood and a hoarse voice as symptoms to watch for, and says a doctor should be consulted if any occur. Vomiting blood or being unable to swallow fluids is an emergency: call 999 or go to A&E.

Diagnostic endoscopy and surveillance are normally arranged through NHS gastroenterology after GP referral. Private gastroscopy is widely available for people who want quicker access; the NICE intervals still apply, so ask whether the endoscopist uses the Seattle biopsy protocol, whether you will receive a written report with the Prague measurements, and who will recall you when the next scope is due.