The esophagus is the part of the digestive tract that connects the mouth and throat with the stomach, and is commonly called the “food pipe” by non physicians. The most common condition I see in patients with esophageal problems is known as acid reflux, or GERD (GastroEsophageal Reflux Disease). In GERD, acid made in the stomach travels backwards up into the esophagus, usually causing symptoms of chest burning or pain. Besides just causing heartburn, the acid can actually cause damage to the tissue lining the esophagus, resulting in inflammation, ulcers, and scarring. Not all patients with GERD develop tissue damage, but of those that do, a significant portion can progress to a condition called Barrett’s esophagus, and some of them can then develop esophageal cancer.
When Barrett’s develops, the cells that line the esophagus change. The inner lining of the esophagus is called the mucosa, and in Barrett’s the mucosa becomes composed of cells that are normally present lining the small intestine. These cells are initially benign, but it is abnormal for them to be found there. Over time, the Barrett’s mucosa can become precancerous, a condition known as dysplasia. When dysplasia is severe, there is a high risk of cancer developing.
Barrett’s esophagus is most common in Caucasian males 50 and older, although it can occur in anyone. The main risk factor is GERD, which typically presents as frequent heartburn. Other risks include smoking, obesity, and family history. It should be tested for in someone with these risk factors, and I perform endoscopy to look for it commonly in patients with frequent GERD symptoms. Endoscopy is a procedure where I use a flexible scope which is passed through the mouth into the esophagus under sedation, and with which I can visually inspect the lining of the esophagus and take small biopsies of it. Barrett’s is diagnosed when a pathologist sees intestinal cells in a biopsy of the esophageal mucosa. The pathologist can also identify dysplasia and cancer.
Once Barrett’s is diagnosed, we have to decide what to do about it. If no dysplasia is present, then the treatment is to put the patient on an acid lowering medication called a PPI and to counsel them to stop smoking, lose weight, etc. The patient should then be entered into a surveillance program, where they have an endoscopy and biopsies done every three years to look for any signs of progression to dysplasia or early stage cancer. If these are detected either initially or on follow up, treatment consists of eradicating the abnormal mucosa by ablating or destroying it with radiofrequency energy (RFA), or removing it through the scope with EMR (endoscopic mucosal resection). These techniques are non-surgical and highly effective, and usually done in advanced endoscopy centers.
So the main point is that frequent heartburn may be more than just a nuisance, and could be a sign of a more serious condition such as Barrett’s esophagus. While most people with GERD and Barrett’s never progress to esophageal cancer, detection, surveillance, and early treatment can be lifesaving and prevent the need for major surgery. If you get heartburn frequently you should talk to you doctor about it.