Barrett’s Esophagus - American Family Physician

managed in the primary care setting. Surveys suggest that approximately 20 percent of U.S. adults have symptoms of GERD at least once a week.4 A subgroup of patients with GERD develop severe complications that include erosive esophagitis, stricture formation, Barrett’s esophagus, and adenocarcinoma of the esophagus. Because Barrett’s esophagus is thought to be associated with the development of adenocarcinoma, it is imperative that primary care physicians be familiar with Barrett’s esophagus, its association with GERD, and its diagnosis and management. The overall prevalence of Barrett’s esophagus in the general population is difficult to estimate, because approximately 25 percent of persons with Barrett’s esophagus have no symptoms of reflux.5 It is known, however, that the incidence of adenocarcinoma of the esophagus has risen sharply in the past few decades. The results of one study6 note that the incidence of adenocarcinoma in white men has increased by more than 350 percent since the mid-1970s. Identification of patients at risk for adenocarcinoma of the B arrett’s esophagus was first described in 1950 by Norman Barrett, who reported a case of chronic peptic ulcer in the lower esophagus that was covered by epithelium.1 Barrett’s esophagus can be defined simply as columnar metaplasia of the esophagus. Patients who have columnar epithelium that measures 3 cm or more from the gastroesophageal junction are said to have traditional, or “long-segment,” Barrett’s esophagus, while patients with a measure less than 3 cm have “short-segment” Barrett’s esophagus.2 In 1998, the American College of Gastroenterology (ACG) defined Barrett’s esophagus as “a change in the esophageal epithelium of any length that can be recognized at endoscopy and is confirmed to have intestinal metaplasia by biopsy of the tubular esophagus and excludes intestinal metaplasia of the cardia.”3 Gastroesophageal reflux disease (GERD) Gastroesophageal reflux disease (GERD) is a condition commonly managed in the primary care setting. Patients with GERD may develop reflux esophagitis as the esophagus repeatedly is exposed to acidic gastric contents. Over time, untreated reflux esophagitis may lead to chronic complications such as esophageal stricture or the development of Barrett’s esophagus. Barrett’s esophagus is a premalignant metaplastic process that typically involves the distal esophagus. Its presence is suspected by endoscopic evaluation of the esophagus, but the diagnosis is confirmed by histologic analysis of endoscopically biopsied tissue. Risk factors for Barrett’s esophagus include GERD, white or Hispanic race, male sex, advancing age, smoking, and obesity. Although Barrett’s esophagus rarely progresses to adenocarcinoma, optimal management is a matter of debate. Current treatment guidelines include relieving GERD symptoms with medical or surgical measures (similar to the treatment of GERD that is not associated with Barrett’s esophagus) and surveillance endoscopy. Guidelines for surveillance endoscopy have been published; however, no studies have verified that any specific treatment or management strategy has decreased the rate of mortality from adenocarcinoma. (Am Fam Physician 2004;69: 2113-8,2120. Copyright© 2004 American Academy of Family Physicians.) Barrett’s Esophagus