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- v. 7(7); Christmas 2011
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Gastroenterol Hepatol (NY).July 2011; 7(7): 461-464.
Richard E. Sampliner, arts
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G&HHow were patients with non-dysplastic Barrett's esophagus traditionally treated?
RSTreatment of non-dysplastic Barrett's esophagus consisted of interval endoscopy with systematic biopsies (4 quadrants every 2 cm). Although this procedure has been routinely used for many years, analyzes have shown that it is not cost effective. There has also been a problem with the method of biopsies. Biopsies can be time consuming, especially when sections of Barrett's esophagus are 5 cm or longer. Studies have shown that the longer a segment of Barrett's esophagus is, the fewer biopsies an endoscopist takes every 2 cm. For example, a 10 cm Barrett's esophagus would likely require 6 levels of 4-quadrant biopsies, for a total of 24 biopsies. However, it is unlikely that the average practitioner would take that many biopsies as it would take an additional 15-20 minutes. In addition, each level of samples must be placed in a separate bottle after collection, so more than 1 assistant is needed during the procedure - an additional person is needed to manage all biopsies. More biopsies also translate into higher costs for the pathologist.
G&HWhy has ablation therapy historically been used for dysplastic - but not non-dysplastic - Barrett's esophagus?
RSAblation therapy has become the standard for the treatment of dysplastic Barrett's esophagus due to the positive results of the AIM dysplasia study. The results of this very high quality, randomized, sham-controlled trial of low grade dysplasia and high grade dysplasia are published inHet New England Journal of Medicine. In Europe, there was a randomized trial of equivalent quality of radiofrequency ablation versus endoscopic resection of the entire Barrett's esophagus. This study showed that radiofrequency ablation was technically easier to use and had fewer complications than endoscopic resection. Circumferential resection of Barrett's esophagus was associated with a high frequency of strictures. These 2 high quality, randomized trials demonstrated the efficacy of radiofrequency ablation; the quality of this evidence is as good as the quality of evidence required for a pharmaceutical to receive approval from the US Food and Drug Administration.
G&HIs ablation therapy currently performed regularly in non-dysplastic Barrett's esophagus patients?
RSYes, ablation is now commonly performed in patients with non-dysplastic Barrett's esophagus. Because non-dysplastic Barrett's esophagus is the most common form of Barrett's esophagus (95%), ablation is performed even more frequently in non-dysplastic than in dysplastic Barrett's esophagus patients. There are an estimated as many as 3 million people with Barrett's esophagus in the United States. About 1.5% have high grade dysplasia and early cancer, and about 5% have low grade dysplasia. No more than 10% of all individuals with Barrett's esophagus would meet the criteria for the dysplasia studies.
G&HWhat have studies to date shown regarding the use of ablation therapy for the treatment of non-dysplastic Barrett's esophagus?
RSThe results so far have been very favorable. Fleischer and co-workers conducted the largest trial in this field; this study - which was comparable to an open-label study in that all patients were treated with ablation - had a 5-year follow-up and reported a very high success rate (97%) for eradication of the entire Barrett's esophagus of a patient (biopsy - documented).
Ablation therapy has been shown in multiple studies to eradicate the entire segment of Barrett's esophagus. The endpoint of therapy is the eradication of all intestinal metaplasia and the entire Barrett esophagus segment; the same endpoint is used regardless of whether Barrett's esophagus is non-dysplastic or dysplastic and should be documented with a systematic biopsy protocol.
Long-term durability has been demonstrated for new squamous epithelium after radiofrequency ablation. In addition to the Fleischer study, the randomized sham-controlled study has been expanded to a follow-up of 2 to 3 years (in press). Recurrence of Barrett's esophagus can occur if a patient stops treatment with proton pump inhibitors.
G&HWhat side effects and complications have been reported in these studies?
RSAblation is very safe; in fact, there has never been a modality for treating these patients with such a low side effect profile. The most common side effects are local (chest pain, dysphagia) and transient, usually lasting only a few days. The main side effect is post-therapy narrowing, which can usually be treated with just 1 or 2 dilations. Perforation only occurs if the ablation protocol is not followed. The need for hospitalization is unusual: 1%. Radiofrequency ablation is not associated with a risk of death.
G&HHow many ablation sessions are usually required in these patients?
RSThe number of sessions depends on the length of Barrett's esophagus. A segment less than 3 cm long usually takes 1 or 2 sessions. The focal probe (HALO 90, Barrx Medical) is only 2 cm long and 1 cm wide and fits on the end of a standard endoscope. The endoscopist moves the probe around the circumference of Barrett's esophagus and then pulls it up toward the mouth to treat the more proximal part of the segment. The probe manufacturer's recommendation is not to treat more than 6 cm at a time. Treating 6 cm would probably take at least 2-3 sessions, while treating 10 cm would probably take 4-6 sessions.
There is a 3 cm radiofrequency balloon (HALO 360, Barrx Medical) that can be used for longer segment Barrett's esophagus. This is a more complex technique that is often not available in the setting of ambulatory endoscopy. A small scope is placed into the esophagus along with the balloon to ensure proper placement. Treatment of the distal esophagus is difficult because this part of the esophagus is often tortuous, even in young patients. The esophageal-gastric junction presents a particular challenge to the endoscopist because of its larger opening. One of the reasons for the introduction of the focal device was to treat areas that the balloon missed.
G&HIs supervision necessary after ablation therapy?
RSThe need for surveillance after ablation therapy has not yet been defined. In the most recent American College of Gastroenterology guidelines for the treatment of Barrett's esophagus, the authors suggested that 3 consecutive endoscopic surveillances without Barrett's esophagus might be sufficient. However, this issue has not been addressed in a sufficient number of patients with a sufficiently long follow-up.
Barrx Medical is in the process of compiling a nationwide registry, aiming to have 3,000 to 4,000 patient-years of follow-up with the power to document reduced cancer progression. The results of this registration will help answer the question of whether continued monitoring is necessary after ablation.
G&HDo you expect ablation therapy to become a first-line treatment option for non-dysplastic Barrett's esophagus patients?
RSI don't think we're there yet. Ablation is currently only a first-line treatment in non-dysplastic Barrett's esophagus patients with a family history of esophageal adenocarcinoma. More data is needed to define other non-dysplastic Barrett's esophagus patients eligible for ablation.
The aforementioned published randomized studies were conducted in centers of great interest in Barrett's esophagus. Publications from other training centers indicate that an endoscopist with an interest in Barrett's esophagus and experience in the technique can be as successful in ablation therapy as endoscopists at a large center. The learning curve for ablation therapy in non-dysplastic Barrett's esophagus has not yet been defined, but it is reasonable to expect a gastroenterologist to treat at least 50-100 patients annually to begin this procedure. This procedure requires skill in correctly recognizing Barrett's esophagus, experience with contemporary endoscopy, and a working relationship with pathology colleagues who can adequately read biopsy specimens.
Part of the concern about the treatment of non-dysplastic Barrett's esophagus patients may stem from an irrational opposition to ablation therapy in general. Each endoscopist must make their own decision about which procedure to perform. Ablation therapy requires considerable endoscopic expertise. Especially in the context of high grade dysplasia or early cancer when nodular areas are recognized, an endoscopic resection is necessary prior to performing radiofrequency ablation. Endoscopic resections are generally not performed by most practicing gastroenterologists in the United States. Excellent contemporary radiology and endoscopic ultrasound are also necessary techniques to evaluate patients with early cancer.
G&HShould ablation therapy be avoided in certain patients with non-dysplastic Barrett's esophagus?
RSAblation therapy is not recommended in patients with extremely long sections of Barrett's esophagus that require many procedures. Similarly, the procedure would be difficult in patients with technical difficulties, such as pseudodiverticula in the esophagus, as diverticula usually cannot be entered with the focal radiofrequency ablation device. Ablation should also be avoided in high-risk patients, such as those with cardiopulmonary disease or in whom anticoagulant therapy cannot be discontinued.
G&HDoes the presence of gastroesophageal reflux disease affect the treatment of Barrett's esophagus?
RSThe presence of gastroesophageal reflux disease (GERD) usually does not affect patient management, although patients with GERD and Barrett's esophagus may find it more difficult to control their symptoms. Patients with "GERD-plus disease" have symptoms that are not eliminated with proton pump inhibitor therapy. They may have altered esophageal perception and may need additional therapeutic options.
G&HDo proton pump inhibitors play a role in ablation therapy of non-dysplastic Barrett's esophagus patients?
RSAbsolute. Basically, ablation therapy is a combination therapy with a proton pump inhibitor administered at a BID dose. This therapy maximizes the chance of squamous epithelial repair in patients undergoing ablation therapy. There is some suggestion that proton pump inhibitor therapy alone may actually reduce the progression of dysplasia.
G&HHas a cost-effectiveness analysis been performed in this patient population?
RSAblation therapy has been shown to be more cost-effective than surveillance. At least 2 studies have been conducted on this topic, one by Hur and colleagues and one by Inadomi and colleagues. If no supervision is required after ablation, the procedure is very cost-effective.
G&HAre there ongoing or upcoming studies in this patient population that you anticipate?
RSA large study of non-dysplastic Barrett's esophagus patients is currently underway in the UK; this study has 4 arms: aspirin versus no aspirin and low dose versus high dose proton pump inhibitor therapy. (There is no placebo arm.) The study will show both the impact of the proton pump inhibitor alone and the impact of the aspirin and the proton pump inhibitor together. If this study shows that aspirin and proton pump inhibitors can prevent the progression of dysplasia, they could represent a more cost-effective treatment modality than ablation therapy. However, this study will take several years to complete as the researchers are currently recruiting more study participants.
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Barrett's esophagus without dysplasia
Usually, you don't need treatment at this stage. But your healthcare provider will want to monitor the condition. You'll need to have an upper endoscopy every two to three years.
Radiofrequency ablation: The non-dysplastic BE in patients is managed by radiofrequency ablation (RFA) therapy. The RFA process involves radiofrequency energy to ablate the damage tissue through endoscopy. Depending on cryotherapy, two methods are available.How successful is ablation for Barrett's esophagus? ›
How effective is radiofrequency ablation therapy? Overall, RFA completely removes Barrett's esophagus and dysplasia in a high proportion of patients, as shown in results from multiple clinical studies. The success rate is about 80 to 90 percent.What is non dysplastic Barrett's esophagus? ›
It means that your biopsy showed Barrett's esophagus that contains some cells that are abnormal, but not abnormal enough to consider them dysplasia. Often, people with these changes have a lot of reflux, which irritates the cells in the esophagus so that the cells look abnormal under the microscope.How worried should I be about Barrett's esophagus? ›
Barrett's esophagus is associated with an increased risk of developing esophageal cancer. Although the risk of developing esophageal cancer is small, it's important to have regular checkups with careful imaging and extensive biopsies of the esophagus to check for precancerous cells (dysplasia).What is the new treatment for Barrett's esophagus? ›
New technology allows for nonsurgical treatment of Barrett's esophagus with dysplasia and some cases of early esophageal cancers. These procedures include: Radiofrequency ablation (RFA) – RFA delivers energy directly to Barrett's and precancerous cells, causing them to die and be replaced with normal cells.What are the side effects of Barrett's esophagus ablation? ›
Complications of RFA include chest discomfort, esophageal stricturing, and bleeding. However, chest discomfort is usually transient and mild, strictures are generally amenable to dilation, and clinically significant bleeding is rare.What are esophageal problems after ablation? ›
Symptoms of esophageal injury include pleuritic chest pain, nausea, fever, throat pain, and abdominal pain. Endoscopic sonography has demonstrated that mucosal changes of the esophagus after ablation can be reversible with bowel rest, antimicrobials, and PPIs but may progress to esophageal perforation and AEF. Han H.C.What happens after an ablation of the esophagus? ›
Patients who have RFA in the esophagus often experience chest discomfort for a few days after the procedure. Your doctor will ask you to consume a liquid diet for 2 days, then soft or pureed food for 2 days, and to continue taking your proton pump inhibitor acid-reducing medicine twice a day.How long does it take for your esophagus to heal after ablation? ›
This tissue sloughs off over 48 to 72 hours following the procedure. Over a period of six to eight weeks, this tissue is replaced by normal (squamous) lining.
FAQs: How much discomfort can I expect after the esophageal ablation? The procedure itself is not usually painful, as the patient is sedated for the procedure. It is, however, common for the patient to feel chest discomfort and discomfort with swallowing for no longer than seven days after the procedure.How do you keep your Barrett's esophagus from progressing? ›
Avoiding trigger foods—such as chocolate, coffee, fried foods, peppermint, spicy foods, and carbonated beverages—can help reduce symptoms. These foods increase acid levels in the stomach. Doctors also recommend eating multiple small, frequent meals instead of a few large ones.How long does it take for Barrett's esophagus to become cancerous? ›
5% of patients with Barrett's Esophagus develop esophageal cancer within 5-8 years of diagnosis. The incidence of high grade dysplasia progressing to cancer is 10% (range 6%-19%) per year. The incidence of low grade dysplasia progressing to cancer is 0.6% per year.Can you live a long life with Barrett's esophagus? ›
Furthermore, patients with Barrett's esophagus appear to live approximately as long as people who are free of this condition. Patients often die of other causes before Barrett's esophagus progresses to cancer. Monitoring for precancerous changes is recommended for most patients with Barrett's esophagus.What is the life expectancy of someone with Barrett's esophagus? ›
The mean life expectancy following a diagnosis of Barrett esophagus is 22 years; the lifetime risk of requiring intervention for high-grade dysplasia or esophageal adenocarcinoma is between one in five and one in six patients.How often should you have an endoscopy if you have Barrett's esophagus? ›
Your doctor will likely recommend: Periodic endoscopy to monitor the cells in your esophagus. If your biopsies show no dysplasia, you'll probably have a follow-up endoscopy in one year and then every three to five years if no changes occur.How fast does Barrett's esophagus progress? ›
Barrett esophagus (BE) is a precancerous condition that progresses to high-grade dysplasia (HGD) at an estimated rate of 0.5% to 0.9% per year.What are the signs of Barrett's esophagus getting worse? ›
- heartburn that gets worse or wakes you from sleep.
- painful or difficult swallowing.
- Feeling like food is stuck in your esophagus.
- constant sore throat, sour taste in your mouth, or bad breath.
- weight loss.
- blood in your stool.
What's more, greater intakes of folate and vitamin B6 were linked to a lower risk of esophagus cancer and a condition called Barrett's esophagus, both of which are potential complications of long-term GERD ( 8 ).
Drinks such as ginger tea, certain fruit and vegetable juices, and plant-based milks may benefit people experiencing acid reflux and heartburn. Avoiding citrus juices, carbonated beverages, and alcohol can also help to reduce symptom frequency and severity.
The first line of treatment is often surveillance and medication. If the biopsy shows no or even low-grade dysplasia, we may simply monitor the patient for changes. That may mean a follow-up endoscopy in six months to a year and, for some patients, daily medication.Can Barrett's esophagus come back after ablation? ›
About one-third of patients with Barrett's esophagus can expect recurrence of intestinal metaplasia by 2 years after obtaining complete remission with radiofrequency ablation.What can you not eat after an ablation? ›
Eat heart-healthy foods. These foods include vegetables, fruits, nuts, beans, lean meat, fish, and whole grains. Limit sodium, alcohol, and sugar.What is considered soft diet after esophageal ablation? ›
Cooked cereals without nuts or dried fruits, ready to eat cereals softened in milk. Noodles, potatoes, and pasta. Fresh or "doughy" breads may cause “sticking”. Avoid all fresh bread, rolls, muffins, biscuits, and rice.Can an ablation damage your esophagus? ›
Esophageal perforation is a dreaded complication of atrial fibrillation ablation that occurs in 0.1% to 0.25% of atrial fibrillation ablation procedures. Delayed diagnosis is associated with the development of atrial-esophageal fistula (AEF) and increased mortality.What are common symptoms after ablation? ›
In the days after the procedure, you may experience mild symptoms such as an achy chest and discomfort, or bruising in the area where the catheter was inserted. You might also notice skipped heartbeats or irregular heart rhythms. Most people can return to their normal activities within a few days.Why does my throat hurt after ablation? ›
Effects from anesthesia are normal. You might have a sore throat or coughing, and you might feel groggy for hours or even days after the procedure. Your resting heart rate will likely increase. It will go up 10-20 beats per minute for a few months, then will likely settle into a lower rhythm after that.Can you live a normal life after ablation? ›
After a successful catheter ablation procedure, most people can return to a normal, active lifestyle and experience improvement in their quality of life.What is the life expectancy of an ablation? ›
After a single ablation procedure, arrhythmia-free survival rates were 40%, 37%, and 29% at one, two, and five years.What happens to your body after an ablation? ›
You may have strong cramping, nausea, vomiting, or the need to urinate often for the first few days after the procedure. Cramping may continue for a longer time. Do not to douche, use tampons, or have sex for 2 to 3 days after an endometrial ablation, or as advised by your health care provider.
Immediately after ablation procedure
catheter lab you will have a dressing or pressure bandage applied to the groin and you will likely need to remain in bed for 4-6 hours. your groin, your leg should remain still and you should not bend your leg or sit up.
After catheter ablation, you should avoid heavy lifting and strenuous exercise for at least three days. Talk with your provider about when it's safe to return to physical activity. After surgical ablation, you'll spend about a week in the hospital.Why is sucralfate prescribed after ablation? ›
Pantoprazole (protonix) and/or sucralfate (carafate) - These medications help protect the stomach and esophagus (food pipe). If prescribed after ablation, protonix is taken once daily for 1 month and carafate is taken three times per day for 2 weeks.Am I awake during ablation? ›
You will be awake during your procedure but before it begins your doctor will give you sedation to help you relax. This is given through a cannula in your arm. During the procedure: Your groin (the top of your leg) area is shaved.What is the failure rate for ablation? ›
Paroxysmal atrial fibrillation can be eliminated in 70-75 percent of patients with a single procedure. When the procedure is repeated in patients who still have atrial fibrillation after the first procedure, the overall success rate is approximately 85-90 percent.How long are you hospitalized after an ablation? ›
A cardiologist performs catheter ablation in the hospital. You will need to stay at the hospital for six to eight hours after the procedure. Depending on your condition, you may go home that day or spend the night at the hospital.Does Barrett's esophagus always turn into dysplasia? ›
About 10% of the patients with gastroesophageal reflux may be expected to develop Barrett's esophagus, and in about 10% of the patients with Barrett's esophagus, dysplasia occurs.Does Barrett's esophagus always progress? ›
This long-term irritation causes what's known as metaplasia and dysplasia – or abnormal changes to the cells – which promotes cancer growth. Keep in mind, GERD will not always progress into Barrett's esophagus, and Barrett's esophagus will not always progress into cancer, adds Dr.Is oatmeal good for Barrett's esophagus? ›
Foods that are good to have in your diet if you have Barrett's esophagus include: Fruits, vegetables, herbs, oats, beans, quinoa, brown rice, lentils, whole-grain bread, and whole-grain pasta.What is the first stage of Barrett's esophagus? ›
The stages of Barrett's esophagus are: non-dysplastic (no cancerous tissue present) low-grade dysplasia (minor cell changes found) high-grade dysplasia (extensive cell changes found, but not yet cancer)
The stages, or grades, of Barrett's are: Non-dysplastic, Indefinite, Low grade Dysplasia, and High Grade Dysplasia, which can lead to Intramucosal Carcinoma.What is the main cause of Barrett's esophagus? ›
Barrett's esophagus results from long-term exposure to stomach acid. When you have gastroesophageal reflux disease (GERD), stomach acid backs up into your esophagus. This frequent acid exposure causes inflammation and damage to the cells in your esophagus.What does Barrett's esophagus without dysplasia mean? ›
Having Barrett's esophagus without dysplasia means your provider didn't detect precancerous cells. Usually, you don't need treatment at this stage. But your healthcare provider will want to monitor the condition. You'll need to have an upper endoscopy every two to three years.What aggravates Barrett's esophagus? ›
In people with Barrett's esophagus who are affected by reflux symptoms, the symptoms may be triggered by certain foods, especially spicy, citric or hot foods, as well as other stimuli, such as alcohol and coffee.How many stages does Barrett's esophagus have? ›
There are three stages of Barrett's esophagus, which range from intestinal metaplasia without dysplasia to high-grade dysplasia.Is Barrett's esophagus always cancerous? ›
Barrett's oesophagus can increase your risk of cancer of the oesophagus, although the risk is still small. Many people with Barrett's oesophagus do not develop cancer. Between 3 and 13 people out of 100 (between 3 and 13%) with Barrett's oesophagus in the UK will develop oesophageal adenocarcinoma in their lifetime.How long should you take omeprazole for Barrett's esophagus? ›
Omeprazole comes as an over-the-counter (OTC) and prescription medication. Generally, you shouldn't use OTC omeprazole for longer than 14 days unless directed by a healthcare provider. For prescription omeprazole, you should take it as prescribed. Taking omeprazole for too long can cause side effects.Is Barrett's esophagus high risk for Covid? ›
This study demonstrated that multiple organoid cell lines derived from human Barrett's epithelium expressed ACE2 receptors and TMPRSS2 and proved to be susceptible to SARS-CoV-2 infection. Therefore, the logical concern is that patients with Barrett's esophagus might be more susceptible to COVID-19 infection.What is the best treatment for Barrett's esophagus? ›
Preferred treatments include: Endoscopic resection, which uses an endoscope to remove damaged cells to aid in the detection of dysplasia and cancer. Radiofrequency ablation, which uses heat to remove abnormal esophagus tissue. Radiofrequency ablation may be recommended after endoscopic resection.What is the best thing to take for Barrett's esophagus? ›
Proton pump inhibitors (PPIs) are drugs that block the three major pathways for acid production. PPIs suppress acid production much more effectively than H2 blockers. PPIs are the most effective medication for healing erosive esophagitis and providing long-term control of GERD symptoms.
Patient's ages are as follows. Conclusion: Male gender and Caucasian race are certainly strong risk factors for Barrett's esophagus, but perhaps increased age should be secondary. 1/3 of patients in this study were diagnosed prior to age 50, and 72% were diagnosed prior to age 55.What are the side effects of radiofrequency ablation for Barrett's esophagus? ›
Complications of RFA include chest discomfort, esophageal stricturing, and bleeding. However, chest discomfort is usually transient and mild, strictures are generally amenable to dilation, and clinically significant bleeding is rare.What vitamins are good for Barrett's esophagus? ›
What's more, greater intakes of folate and vitamin B6 were linked to a lower risk of esophagus cancer and a condition called Barrett's esophagus, both of which are potential complications of long-term GERD ( 8 ).
Because Barrett's esophagus is considered to be a potentially pre-cancerous condition, medical attention is necessary. Some natural remedies, such as peppermint oil or ginger tea, may be helpful for managing symptoms, but there are not any natural remedies that have been found to reverse the disease.How fast can Barrett's esophagus progress? ›
Barrett esophagus (BE) is a precancerous condition that progresses to high-grade dysplasia (HGD) at an estimated rate of 0.5% to 0.9% per year.