DEAR MAYO CLINIC:

I've had acid reflux for years and was recently diagnosed with intestinal metaplasia. Does this mean I'm going to get Barrett's esophagus? Is there anything I can do, other than wait and see? Are there any treatments available?

ANSWER:

Gastroesophageal reflux disease (GERD), a condition where acid from the stomach "refluxes" or backs up into the esophagus and causes heartburn, affects 60 million people in the United States.

About 10 percent of patients with chronic acid reflux go on to develop Barrett's esophagus. In this condition, the cells in the lining of the esophagus change in appearance due to irritation from the stomach acid. The cells in the lower esophagus change and come to resemble cells from the stomach or intestine. Intestinal metaplasia of the esophagus, the condition you mentioned, is another name for Barrett's disease.

While patients who have Barrett's esophagus might not experience any new symptoms, the condition increases the risk of esophageal cancer. And the incidence of esophageal cancer, although still uncommon, is increasing more quickly than any other cancer in the United States. For patients with Barrett's, the lifetime risk of developing esophageal cancer is 10 percent.

With Barrett's, esophageal cells change slowly over the years. The first stage is intestinal metaplasia. The second stage is low-grade dysplasia, where some cells show some atypical changes. And in the next phase, high-grade dysplasia, most cells show abnormal changes. None of these changes is cancer. However, some patients with high-grade dysplasia may advance to cancer.

Typically, patients with intestinal metaplasia are regularly monitored via endoscopy for changes in the cells of their esophagus. The physician passes a lighted tube called an endoscope into the esophagus, which allows the physician to see changes in esophageal tissue. Tissue samples are routinely taken for examination (biopsy).

You probably underwent this procedure to determine your diagnosis. If so, your doctor likely suggested a follow-up endoscopy in one year. If the follow-up procedure does not detect changes, the procedure may then be repeated every three years. If Barrett's worsens or progresses to cancer, surgical and nonsurgical treatment options are available.

You can also consider treating your condition now, before any changes occur. Last year, Mayo Clinic published results of a study of 50 patients in your situation. They were treated with radiofrequency ablation, which burns away abnormal esophageal cells. At the five-year mark, 46 of the 50 patients had no signs of Barrett's esophagus. For the other four patients, an additional radiofrequency ablation treatment eliminated abnormal cells.

The U.S. Food and Drug Administration approved radiofrequency ablation to treat Barrett's esophagus in 2003. But it hasn't been routinely used for early stages of the disease, as was done in this study. Mayo physicians will continue to monitor these patients in hopes that this treatment also leads to a reduction in the cancer associated with Barrett's. If more studies confirm these results, early treatment may eventually eliminate the wait-and-watch approach and the need for repeated endoscopies.

On another front, the expectation is that genetic markers eventually will help identify which patients are likely to advance from Barrett's esophagus to esophageal cancer. This knowledge would allow treatment of high-risk patients to prevent cancer development. And, no such treatment would be required for the majority of Barrett's patients who are very unlikely to go on to esophageal cancer.

Continuing to work with your physician to manage acid reflux symptoms is important. Strategies to manage those symptoms include acid-blocking medications and lifestyle changes, such as eating smaller meals, not smoking, and avoiding foods that trigger heartburn.

David Fleischer, M.D., Gastroenterology, Mayo Clinic in Arizona

 

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