Overview.
食管下段鳞状上皮被柱状上皮替代的病理变化
可无症状，也可表现为以反酸、烧心为主的症状
不明确，可与胃食管反流病相关
一般治疗、药物治疗、手术治疗、内镜下治疗等
What is Barrett’s esophagus?
Definition.
Barrett’s esophagus, also known as Barrett’s esophagus, is a pathological change in which the squamous epithelium at the lower end of the esophagus is replaced by columnar epithelium (known as metaplasia), and the junction line between squamous and columnar epithelium is moved upward by more than 1 cm relative to the gastroesophageal junction.
The etiology of the condition is unclear, and it may be a complication of GERD. Symptoms are mostly related to GERD, with acid reflux and heartburn predominating.
Types
(1) According to the pathology, it can be divided into fundic type, cardia type and special intestinal epithelioid metaplasia type.
Fundic type: characterized by the presence of mural cells and principal cells, and containing small concave and fundic glands, which can secrete gastric acid and pepsin at the same time.
Cardia type: characterized by the presence of cardia mucous glands and does not contain mural cells and principal cells.
Specialized intestinal epithelial hyperplasia type: has the pathological characteristics of incomplete intestinal hyperplasia epithelium and functions similar to the small intestinal mucosa.
(2) Barrett’s esophagus can be categorized according to the degree of xenoplasia: no xenoplasia, indeterminate xenoplasia, low-grade xenoplasia, high-grade xenoplasia, and intramucosal carcinoma.
(3) Classification according to the length of pyogenic columnar epithelium
Long-segment Barrett’s esophagus: the pyogenic columnar epithelium involves the whole periphery of the esophagus and its length is more than 3 cm.
Short Barrett’s esophagus: the pyogenic columnar epithelium does not cover the entire esophagus, or it covers the entire esophagus but its length is 1-3 cm.
(4) According to endoscopic morphology, it can be categorized into peripheral, lingual and insular types.
(5) According to the Prague CM, “C” represents the length of the peripheral type of pyogenic mucosa, and “M” represents the maximum length of the non-peripheral pyogenic mucosa.
Morbidity
Barrett’s esophagus develops in approximately 10% of patients with chronic GERD.
It is most common in the older age group.
It is more common in males than females, with a male to female ratio of approximately 2:1.
The incidence has been increasing year by year in recent years.
Questions you may be concerned about
Can Barrett’s esophagus return to normal?
There is no evidence to surface which drug can reverse the pyogenic columnar epithelium of Barrett’s esophagus, but the application of acid-suppressing drugs such as omeprazole, supplemented with mucosal protectants such as magnesium aluminum carbonate, prokinetic drugs such as domperidone, etc., or anti-reflux surgery can be effective in controlling the symptoms and preventing further development of the abnormal pyogenic columnar epithelium.
If necessary, the lesion can be resected or ablated to achieve a radical effect or to stop the deterioration of the disease.
What is the probability of Barrett’s esophagus becoming cancerous?
Overall, the probability of Barrett’s esophagus becoming cancerous is less than 1%.
Barrett’s esophagus with xenodysplasia (intraepithelial neoplasia) has a significantly higher risk of developing esophageal cancer than Barrett’s esophagus without xenodysplasia. The higher the degree of heterogeneous hyperplasia, the higher the risk of developing esophageal adenocarcinoma.
Barrett’s esophagus with intestinal epithelial hyperplasia has a greater risk of carcinoma.
Therefore, patients with Barrett’s esophagus should be monitored regularly as prescribed by their doctor.
What are the dietary contraindications for Barrett’s esophagus?
Patients with Barrett’s esophagus should avoid high-fat foods, chocolate, coffee, strong tea, spicy foods, etc. These foods will lower the pressure on the esophageal sphincter and aggravate reflux symptoms. Smoking and alcohol should also be quit.
Regular diet and balanced nutrition should be observed in daily life. It is not advisable to lie down in bed immediately after eating, and eating should be avoided as much as possible 2 hours before going to bed.
Causes
Causes
The cause of Barrett’s esophagus is not clear, and is likely to be related to gastroesophageal reflux disease (GERD), which is associated with the following factors.
Weakened anti-reflux function of the esophagus
The lower esophageal sphincter is a group of muscles located at the junction of the esophagus and the stomach, which prevents gastric contents from flowing back into the esophagus and acts as a barrier. Abnormal function of the lower esophageal sphincter can cause reflux of stomach contents into the esophagus.
Abnormal function of the lower esophageal sphincter can be caused by the following reasons.
贲门失弛缓症手术。
胆囊收缩素以及血管活性肠肽等生物活性物质异常。
大量食用巧克力、浓茶、咖啡、肥肉等油腻食物、柠檬汁以及食醋等。
腹内压增高，如肥胖、过度负重劳动等。
胃内压增高、胃排空延迟等。
Weakened esophageal motility
Normally, if GERD occurs, most of the refluxed material can be squeezed back into the stomach through the regular movement of the esophagus.
However, if esophageal motility is weakened due to various reasons, the above process cannot be completed properly, which in turn triggers GERD.
Weakening of esophageal mucosal barrier defense
After reflux enters the esophagus, the esophagus can resist damage to the esophageal mucosa by virtue of the barrier effect of the mucous membrane on the surface of the esophagus.
Prolonged smoking and alcoholism can cause esophageal motility disorders resulting in mucosal damage, which in turn triggers gastroesophageal reflux.
Risk factors
Family history of Barrett’s esophagus.
Obesity, especially abdominal obesity.
Long-term dietary irregularities, alcoholism, high consumption of high-fat, strong tea, coffee, spicy and irritating foods and drinks.
Taking certain drugs, such as calcium antagonists.
Long-term smoking.
Prolonged high mental tension, anxiety, depression and other bad moods.
Men over 50 years of age are at higher risk of developing the disease than other groups.
Symptoms
Barrett’s esophagus can be asymptomatic.
If there are symptoms, acid reflux and heartburn are the main symptoms. Symptoms are most common 1 hour after meals and are more pronounced when lying down, bending over or coughing, weight-bearing, and during defecation.
Main Symptoms
Acid reflux: the presence of stomach contents in the mouth, or liquid with an acidic flavor.
Heartburn: a burning sensation behind the sternum and sometimes a distinct burning sensation in the throat.
Other symptoms
Pain behind the sternum: This is especially noticeable when eating and swallowing food.
Painful swallowing: pain is noticeable when swallowing, sometimes even when just swallowing saliva.
Difficulty in swallowing: initially inability to swallow solid foods such as vegetables and staple foods, and then inability to swallow liquids such as soy milk and milk.
Complications
Perforation of the esophagus
When the injury involves the whole esophagus, esophageal perforation can be caused by the effect of intra-esophageal pressure; in severe cases, it can cause infection around the perforation.
In the absence of infection, it may manifest as severe pain in the chest; if it is accompanied by infection, it may manifest as high fever and chills, etc. In severe cases, it may also manifest as limb pain.
In severe cases, there may be cold extremities, excessive sweating, bruising of the skin, lips and mouth, and coma.
Esophageal Ulcer
Prolonged irritation of the esophageal mucosa by reflux material may cause breakage of the esophageal mucosa.
It is characterized by retrosternal and/or epigastric pain, dysphagia and retrosternal burning sensation.
Food irritation may aggravate the above symptoms.
Upper gastrointestinal bleeding
Prolonged irritation of the esophageal mucosa by refluxed material may cause bleeding due to breakdown of the esophageal mucosa.
Symptoms such as vomiting blood and black stool are manifested.
Consultation
Department of Medicine
Gastroenterology
For symptoms such as unexplained acid reflux, heartburn, retrosternal pain, painful swallowing and dysphagia, prompt medical attention is recommended.
Emergency Department
When symptoms such as severe chest pain, difficulty in swallowing, vomiting blood, or blood in stool occur, it is recommended to consult the Emergency Department immediately.
Preparation for medical treatment
Preparation for medical treatment: registration, preparation of documents, common problems
Tips for seeking medical treatment
Keep a detailed record of symptoms and patterns for your doctor’s reference.
Preparation Checklist
症状清单
Pay particular attention to the time of onset of symptoms, special manifestations, etc.
How long has it been since the symptoms started, are they persistent or occasional?
What aggravates or alleviates the symptoms?
Are there symptoms of acid reflux?
Are medications taken to relieve symptoms?
Are there any symptoms of dysphagia?
病史清单
Any previous heart disease, such as coronary heart disease, cardiomyopathy, etc.?
Have you ever suffered from upper gastrointestinal diseases, such as gastroesophageal reflux disease (GERD)?
What are your usual living habits, regular diet, smoking and drinking?
Have you been taking certain medications for a long time, what kind of medications have you been taking and how long have you been taking them?
检查清单
Test results in the past six months, which can be brought to the doctor’s office
Gastroscopy and pathology report
CT examination
用药清单
Medications in the last 3 months, if available, bring the box or package with you to the doctor’s office.
Acid suppressants: omeprazole, lansoprazole, pantoprazole, rabeprazole, famotidine
Prokinetic drugs: domperidone, mosapride
Diagnosis
Diagnosis is based on
Medical history
Long-term use of medications such as calcium antagonists.
Frequent drinking of coffee and strong tea.
Clinical manifestations
Typical symptoms such as heartburn, acid reflux, dysphagia and retrosternal pain may be present.
Esophageal motor function test
食管24小时酸碱度（pH值）监测
Purpose: It can be used to determine whether there is reflux of gastric contents into the esophagus by monitoring the change of pH in the esophagus for 24 hours.
Meaning: If the monitoring result shows a low pH, it indicates the presence of gastric contents in the esophagus.
Precautions: Discontinue relevant medications, such as those that inhibit gastric acid secretion and gastrointestinal stimulants, for 3 days prior to the test as prescribed by the physician.
食管压力测定
Purpose: It can be used to monitor esophageal dynamics and to understand the esophageal motor function and the coordination, barrier function and relaxation function of the upper esophageal sphincter and lower esophageal sphincter.
Significance: The results can help determine the presence or absence of gastroesophageal reflux.
Precautions: Discontinue relevant medications, such as gastrointestinal stimulants and psychotropic drugs, 2 days prior to the test as prescribed by the physician.
影像学检查（X线钡餐造影检查）
Purpose: To determine the presence of esophageal stenosis.
Significance: Although barium X-ray contrast examination cannot diagnose the disease, it can be used for the differential diagnosis of related diseases.
Precautions
检查前3天日遵医嘱禁服某些药物。
检查前2日遵医嘱停用相关药物，如胃肠动力药及精神类药物等。
检查前6～12小时需要禁食禁水。
Endoscopy
Purpose: To clearly see the extent of lesions on the inner wall of the esophagus.
Significance: Endoscopy can not only diagnose Barrett’s esophagus, but also evaluate the condition.
Precautions
检查前
内镜检查前1天晚上尽量吃一些容易消化、清淡的食物，避免饮酒以及进食油腻、辛辣等刺激性食物。
内镜检查前需要禁水4小时，禁食8～10小时。
内镜检查前应避免吸烟，以防引起咳嗽等。
检查中
检查中应避免脱开牙垫，否则会咬伤镜身。
当镜身从口腔插入口咽部时，舌根应放松，尽量经鼻呼吸，咽部放松，避免剧烈恶心。
检查后
检查后应留观半小时以上。
检查后2小时后便可进食，以鸡蛋羹、小米粥等易消化食物为首选。
检查后不可马上饮酒。
Differential Diagnosis
Esophageal Diverticulum
Similarities: Esophageal diverticulum and Barrett’s esophagus can both present with symptoms such as dysphagia and painful swallowing; mid-esophageal diverticulum and supra-diaphragmatic diverticulum can present with symptoms such as chest pain, which are similar to those of Barrett’s esophagus.
Differences: Esophageal diverticula form a sac-like structure in the esophagus that protrudes outward toward the wall, which is significantly different from Barrett’s esophagus, and therefore can be differentially diagnosed by endoscopy and barium X-ray examination.
Esophageal Crohn’s Disease
Similarities: Both esophageal Crohn’s disease and Barrett’s esophagus may present with symptoms such as dysphagia, painful swallowing and chest pain.
Differences: About 70% of patients with esophageal Crohn’s disease have varying degrees of anemia; esophageal Crohn’s disease is usually accompanied by esophageal ulcers and wall thickening, etc. It can be differentiated by routine blood tests, endoscopy, and barium X-ray contrast examination.
Esophageal leukoaraiosis
Similarities: Acid reflux, chest pain and dysphagia may occur.
Difference: Esophageal leukoaraiosis is the invasion of the esophagus by leukoaraiosis, which can attack multiple organs of the human body, and is mainly manifested by recurrent oral and perineal ulcers, skin rashes, erythema nodosum of the lower limbs, iritis of the eyes, and swelling and pain of the joints, etc., and most of the patients’ conditions are in the state of remission-recurrence for a long period of time, so it is possible to differentiate the diagnosis by the symptoms and the course of the disease.
Esophageal cancer
Similarity: Both patients may suffer from acid reflux and heartburn, retrosternal pain, pain and difficulty in swallowing.
Difference: It can be differentiated by endoscopy and histopathology.
Treatment
Purpose of treatment
Control symptoms, cure esophagitis, reduce recurrence and prevent complications.
Treatment Methods
General treatment
Avoid lying down when sleeping. It is recommended to elevate the head of the bed by 15-20 centimeters.
It is not advisable to lie down immediately after eating a meal. It is recommended to stay upright for 30 to 120 minutes after eating a meal.
It is recommended to stay upright for 30 to 120 minutes after meals. Do not eat any food for 2 to 4 hours before bedtime.
It is recommended to avoid foods and medications that decrease the function of the lower esophageal sphincter, such as chocolate, strong tea and coffee, fatty foods such as meat, lemon juice and vinegar.
Obese people have higher intra-abdominal pressure than normal people and are more prone to gastroesophageal reflux, so they should reduce their weight scientifically.
Changing medication habits
避免用唾液吞服药物。
避免服药后直接卧床特别是平躺。
必要时可咨询医生并暂停使用引起食管反流的药物。
Medication
促胃肠动力药
Drug effects: Improve the peristaltic function of the esophagus, promote gastric emptying, so as to reduce the reflux of gastric contents and relieve the esophagitis caused by reflux.
Commonly used drugs: Domperidone, Mosapride, Metoclopramide, Cisapride, etc.
Precautions for use: This drug should be used with caution in infants under 1 year of age, the elderly, nursing mothers and patients with moderate to severe hepatic insufficiency. These drugs are best taken 15-30 minutes before meals.
抑酸药
Drug effects: Proton pump inhibitors (PPI) or H2 receptor antagonists (H2RA) can reduce the secretion of gastric acid, reduce the irritation of gastric acid on the gastric mucosa and esophageal mucosa, and relieve symptoms such as acid reflux and heartburn.
Commonly used drugs: proton pump inhibitors include omeprazole and lansoprazole; H2 receptor antagonists include cimetidine and ranitidine.
Precautions: Infants and young children, allergy to the drug and renal dysfunction patients should be prohibited; the elderly, liver function abnormalities should be careful with the use of this drug.
抗酸药
Effects: Neutralize stomach acid, reduce acid reflux symptoms. However, it is only used for mild, intermittent attacks, and can temporarily relieve symptoms.
Commonly used drugs: aluminum hydroxide gel, calcium carbonate, magnesium aluminum carbonate and so on.
Precautions for use: These drugs should not be taken for a long time or in large quantities. Long-term and large amounts may occur constipation, gastric emptying obstruction and other adverse reactions. Magnesium aluminum carbonate needs to be taken with meals.
黏膜保护剂
Drug effects: protect the mucosa of the stomach and esophagus, reduce the stimulation of the mucosa by gastric acid, and relieve the symptoms of heartburn.
Commonly used drugs: magnesium aluminum carbonate, colloidal bismuth (bismuth potassium citrate, colloidal bismuth pectin), prostaglandins and their derivatives (Rebapatide) and so on.
Precautions for medication: Avoid eating high protein foods, such as eggs and lean meat, during the period of taking medication.
Surgery
抗反流手术治疗
Purpose of Surgery: To prevent gastric contents from refluxing into the esophagus in order to minimize complications such as ulcers, strictures, bleeding, etc., and to prevent further development of the esophageal columnar epithelium.
Applicable people: People who use proton pump inhibitor for long-term maintenance treatment, and people who have poor effect of proton pump inhibitor treatment.
食管切除术
Purpose of surgery: Removal of the diseased esophagus, which can prevent further deterioration of the disease.
It is suitable for patients who present with perforation, or combined with complications such as severe esophageal stenosis and cancer.
Endoscopic treatment
Principles of treatment
低级别上皮内瘤变的巴雷特食管，建议行内镜下切除或者消融治疗，也可不予以治疗，每半年到1年复查一次。
高级别上皮内瘤变的巴雷特食管，建议行超声内镜检查评估病变浸润程度及有无淋巴结转移，同时予以内镜下根治治疗。
Indication: The indication for Barrett’s esophagus endoscopic treatment is Barrett’s esophagus with intraepithelial neoplasia.
Treatment
内镜下根治切除治疗：常用术式包括经内镜下高频电圈套器切除术、内镜下黏膜切除术和内镜黏膜下剥离术。
内镜下消融治疗：常用方法有射频消融、光动力疗法、冰冻疗法、氩离子束凝固术。
Prognosis
Cure
Barrett’s esophagus can be largely cured with aggressive treatment.
Hazards
In untreated cases, development of esophageal ulcers, esophageal strictures, esophageal perforation, esophageal bleeding, and even cancer may occur.
Daily
Daily Management
Dietary management
Regular diet and avoid overeating.
It is recommended to avoid foods that decrease the function of the lower esophageal sphincter, such as chocolate, strong tea and coffee, fatty foods such as fatty meat, lemon juice, and vinegar.
Food should be diversified in daily life, supplemented with fresh vegetables, fruits and essential nutrients contained therein.
Obese people should eat under the guidance of a dietitian with a view to reducing body weight.
Exercise management
Obese people should engage in appropriate and regular exercise to reduce weight scientifically.
Normal weight people can also maintain their weight through regular exercise.
Work and rest management
Ensure reasonable sleep time.
Avoid excessive stress and relaxation.
Others
Quit smoking and drinking.
Positively adjust the bad mood and keep a good mindset.
Follow-up examination
Importance of follow-up examination: Regular follow-up examination helps to find out whether there are complications in time, which is crucial to the treatment effect of the disease.
Follow-up time: Follow the doctor’s instructions for regular follow-up; if symptoms such as acid reflux and heartburn, retrosternal pain, and difficulty in swallowing occur in daily life, it is recommended to consult the doctor in time.
Tests needed at follow-up: People with Barrett’s esophagus or atypical hyperplasia of the esophagus may need endoscopy at follow-up.
Prevention
Diet.
You should not eat too much food, you can eat small and frequent meals.
Eat a light and easily digestible diet, do not eat too greasy.
Do not eat spicy and irritating foods, cold foods, hard foods, or foods that are too hot.
Daily habits
Quit smoking and drinking.
Drink less strong tea, strong coffee, etc.
Don’t lie down in bed immediately after meals, but move around properly; don’t eat before going to bed.
Sleep with a high pillow or elevate the head of the bed.
Ensure smooth bowel movement and do not do actions that cause increased pressure in the abdominal cavity.
Medications
Avoid swallowing medications with saliva.
Avoid lying in bed or flat on your back directly after taking medication.
Stop taking unnecessary medications with your doctor’s consent if necessary.
Other
Exercise: Moderate exercise, especially aerobic exercise, can reduce weight.
Rest: Ensure good mood and sufficient sleep, regular work and rest schedule.
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