What is Gastroesophageal Reflux (GERD)? GERD is a common disorder in which stomach contents such as acid, food, and digestive enzymes reflux into the esophagus. One of the most common and well-known symptoms is heartburn. Approximately 20% of American adults experience heartburn at least twice per week and over 40% experience symptoms of GERD almost monthly. Associated symptoms of GERD may also include abdominal or chest pain, difficulty swallowing, and chronic cough. More severe symptoms include asthma, laryngitis, and sleep disorders. Other individuals may not experience significant symptoms at all. Approximately 1 in 10 people with chronic reflux will develop a precancerous condition called Barrett’s esophagus.
How is GERD diagnosed and treated? GERD is diagnosed by esophageal pH testing, considered the gold standard for diagnosing reflux. Other diagnostic methods include upper endoscopy.
An esophageal pH test measures and records the pH in your esophagus to determine if you have gastroesophageal reflux disease (GERD). The test can also be done to determine the effectiveness of medications or surgical treatment for GERD.
And upper endoscopy is a procedure performed under sedation. A doctor inserts a small flexible tube into the esophagus and stomach to identify characteristic changes that are consistent with a diagnosis of GERD.
Treatment for GERD includes counseling on lifestyle modification such weight loss and diet modification. Other modalities include medical therapy including antacid treatment, and surgical options.
What is Barrett’s esophagus? A result of chronic exposure of the esophagus to the contents of the stomach caused by GERD, Barrett’s esophagus is a precancerous condition affecting the lining of the esophagus, often the lower third. With prolonged acid exposure, normal cells on the inner lining of the esophagus can be injured and genetically altered to grow abnormal precancerous cells. Although the risk is low, if left untreated, these cells are more vulnerable to further mutation and lead to esophageal cancer, which has increased in incidence by over 500% in the past 40 years. It is currently one of the most rapidly rising cancers in the U.S.
There are different degrees of Barrett’s esophagus: non-dysplastic, with a cancer risk of 1 in 200 per year, and higher risk types called dysplastic – further defined as low grade dysplasia and high grade dysplasia. In some studies, high grade dysplasia was associated with a cancer risk of up to 1 in 10 per patient year.
How is Barrett’s esophagus diagnosed? While there is no consensus on who and when to screen, if someone has symptoms suggestive of acid reflux for more than 1-2 years, an endoscopy is typically recommended, especially if over the age of 50. Even if symptoms disappear with treatment, Barrett’s esophagus can still be present, or worse, can progress to more advanced stages. Endoscopy with biopsy is the diagnostic method of choice.
What are the treatment options for Barrett’s Esophagus? Most patients receive high dose proton pump inhibitor (PPI) therapy and periodic surveillance with endoscopy and biopsy. The time intervals of this “watchful waiting” approach varies depending on the severity of a patient’s histologic grade. American College of Gastroenterology guidelines recommend endoscopic surveillance every 6 months for low grade dysplasia and every 3 months for high grade dysplasia. For those with the highest risk for developing esophageal cancer – those with high grade dysplasia and intramucosal cancer – surgical removal of the lower esophagus (esophagectomy) used to be the only treatment option.
Radiofrequency Ablation (RFA). Doctors at Connecticut GI are on the forefront in the treatment of Barrett’s Esophagus. Using an FDA-approved procedure, radiofrequency ablation using the HALO System, the Barrett’s tissue is proactively ablated, reducing the risk of progression to cancer. Radiofrequency ablation uses a small catheter inserted through an endoscope to deliver a short, controlled, burst of heat energy to the esophageal mucosa, which removes the diseased tissue and allows for replacement with normal esophageal lining tissue. The ablation is performed with precise depth control, significantly reducing the risk of complications normally associated with other forms of ablation therapy.
Who should be considered for the ablation procedure? Anyone with Barrett’s esophagus. Candidate patients may have long or short segment Barrett’s and be diagnosed with dysplastic and non-dysplastic disease. For those patients who are appropriate candidates, an ablation procedure may reduce the risk of progression to a more advanced disease state and reduce patient anxiety as it relates to “living with a premalignant condition.”
While initially considered an alternative to esophagectomy for patients at highest risk, especially those who are sub-optimal surgical candidates, radiofrequency ablation is now used to treat all patients with Barrett’s esophagus. Patients have been successfully treated and cured of both non-dysplastic and dysplastic Barrett’s esophagus. The New England Journal of Medicine published a study in 2009 which concluded that radiofrequency ablation was a reasonable option for those patients with dysplastic Barrett’s, both low and high grade. In the largest study conducted with the HALO System, the AIM (Ablation of Intestinal Metaplasia) trial, 98.4% percent of patients treated for non-dysplastic Barrett’s patients were disease-free (at thirty-month follow up). Durability testing found that 92% of patients remained disease free 5 years after initial treatment. The AIM-dysplasia trial, similarly found that over 90% had complete remission.