Is there a cure for my Barrett's esophagus?

No heartburn medication or anti-reflux surgery has been proven to make Barrett's esophagus completely disappear or decrease the risk of developing esophageal adenocarcinoma. The only therapy proven to completely remove the entire Barrett's esophagus is esophagectomy (surgical removal of the esophagus). Esophagectomy is a surgical procedure that is typically reserved for patients who have high-grade dysplasia or cancer and is not recommended for patients who have Barrett's esophagus alone. This is because esophagectomy has a much higher rate of death or serious complications as compared to other, more commonly performed, gastrointestinal tract surgeries. In addition, studies indicate that most patients who have Barrett's esophagus do not develop cancer during follow-up. It is therefore recommended that periodic endoscopic biopsy surveillance be performed to detect patients who are at high risk for cancer rather than removing the esophagus of all Barrett's patients.

Ablation therapy is a relatively new option for the treatment of Barrett's esophagus. This therapy involves destruction of the Barrett's lining with replacement by the normal squamous esophageal lining. This therapy is usually reserved for patients who have high-grade dysplasia or early cancers. An FDA approved therapy, porfimer sodium photodynamic therapy (PDT) has been reported to cause disappearance of high-grade dysplasia in twice as many treated as compared to untreated patients and reduce the cancer rate in half in patients who have high-grade dysplasia. However, because this therapy reduces, but does not eliminate the cancer risk, experts agree that endoscopic biopsy surveillance should be continued indefinitely, until we can better determine who is still at risk for developing cancer after treatment, long-term.

Goal of therapy for Barrett's esophagus

At the present time, the main goal of therapy for patients who have Barrett's esophagus is to control heartburn symptoms and heal esophageal injury caused by GE reflux of acid. It is basically the same therapy as for patients who have gastroesophageal reflux disease (GERD) without Barrett's esophagus. There are three main ways to lessen GERD: medical treatment with acid-suppressive agents, anti-reflux surgery and life-style changes without the use of surgery or medicines. In patients who have Barrett's esophagus, life-style changes alone are rarely effective in completely relieving heartburn symptoms, but can enhance the effects of medical or surgical GERD therapies.

Both successful medical and surgical treatments of GERD control patient symptoms of heartburn and heal esophageal injury and inflammation from acid (esophagitis). Some of the more potent acid-suppressive drugs, such as proton pump inhibitors, as well as anti-reflux surgery, can cause some of the normal squamous esophageal lining to partially grow back inside of the Barrett's esophagus lining. In some patients who have a short segment of Barrett's esophagus, the Barrett's esophagus may appear to be completely replaced by normal squamous lining. It is unknown whether those patients whose Barrett's esophagus has apparently disappeared will have Barrett's tissue detected at a future endoscopy or whether they are safe from ever developing cancer. There are some recent reports that the use of proton pump inhibitors decreases the development of dysplasia, but because many patients with dysplasia, especially low-grade dysplasia do not develop cancer during long-term follow-up, what is important is whether these drugs prevent the development of cancer. At the present time, there is little evidence that proton pump inhibitors prevent cancer in Barrett's esophagus.

Squamous esophageal lining concealing Barrett's esophagus

In some cases, endoscopically normal appearing squamous lining may grow on top of Barrett's lining, as seen in biopsies when they are examined under the microscope by the pathologist. Unfortunately, when this occurs, the Barrett's lining is not only still there, but looks like normal squamous lining through the endoscope. This leads the gastrointestinal (GI) doctor to think that the Barrett's is gone when it is simply buried beneath normal appearing squamous lining. Squamous over Barrett's can be seen commonly in patients on PPI therapy alone and in those patients who have undergone ablation therapy. Recently, more GI doctors who take care of Barrett's patients know about this and take biopsies from both the new squamous lining and the Barrett's lining during endoscopic biopsy surveillance.

Microscopic photo of squamous lining growing on top of the Barrett's lining

A gland of Barrett's esophagus is seen below the normal squamous epithelium in this biopsy. This particular biopsy is not stained with Alcian blue, so the Barrett's goblet cells appear clear rather than dark blue.
Photo courtesy of the late Rodger C. Haggitt MD

Anti-reflux surgery versus medical therapy?

The choice between medical and anti-reflux surgical therapy should be individualized, based on patient preference for one over the other, or chosen because the other has failed to control the patient's GERD. Much larger studies with longer patient follow-up are needed to prove an advantage of one therapy over another in the reversal of Barrett's esophagus or prevention of Barrett's associated cancers. Thus far, most Barrett's experts agree that patients who have Barrett's esophagus should not view anti-reflux surgery as a cancer prevention therapy but rather as a GERD therapy.