GERD and Barrett Oesophagus
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Direct answer
Gastro-oesophageal reflux and Barrett oesophagus are linked, because reflux is the trigger for Barrett oesophagus, a condition in which intestinal metaplasia replaces the squamous lining of the distal oesophagus. Alarm features such as dysphagia, weight loss or bleeding call for endoscopy before long-term proton pump inhibitor therapy. Barrett oesophagus is defined by intestinal metaplasia on biopsy, and its adenocarcinoma risk, though low annually, justifies surveillance only in patients with confirmed metaplasia.
What you must remember
- Alarm features: dysphagia, weight loss, anaemia, gastrointestinal bleeding and persistent vomiting justify endoscopy before empirical acid suppression.
- PPI therapy: a once-daily dose before breakfast for four to eight weeks heals erosive disease, with long-term maintenance guided by relapse.
- Histological definition: goblet cells within the columnar-lined oesophagus confirm intestinal metaplasia, which standard textbook and US criteria require for the diagnosis of Barrett oesophagus (British guidance is less strict).
- Prague classification: the C value records circumferential extent and the M value records maximal extent, both measured from the gastro-oesophageal junction.
- Surveillance: endoscopy with biopsy at intervals set by dysplasia grade and guideline recommendations, with longer intervals when no dysplasia is found.
- Endoscopic therapy: radiofrequency ablation and endoscopic mucosal resection treat high-grade dysplasia and early neoplasia.
- Indian context: Barrett oesophagus and oesophageal adenocarcinoma are less common than squamous oesophageal cancer, but reflux is rising with obesity and dietary change.
A patient with long-standing heartburn
A 58-year-old man has ten years of heartburn and night-time regurgitation that respond well to a proton pump inhibitor.
- Screen for metaplasia: he is a man over 50 with obesity and chronic reflux, which are recognised Barrett risk factors, so endoscopy is performed before the drug is continued long-term.
- Find the segment: the endoscopy shows a salmon-coloured columnar segment just above the junction.
- Confirm on biopsy: biopsies show intestinal metaplasia with goblet cells but no dysplasia.
- Stage and continue treatment: the segment is recorded by its Prague C and M values, the proton pump inhibitor is continued, and surveillance is arranged at an interval set by the guideline for non-dysplastic disease.
- Contrast an alarm case: a 66-year-old with progressive dysphagia and six kilograms of weight loss has an ulcerated mass at the junction, which is a malignancy work-up rather than Barrett surveillance.
- Counsel the patient: lifestyle advice on weight, meal timing and head-of-bed elevation supports the drug treatment, and the patient is told that heartburn does not reliably track the presence of metaplasia, so surveillance continues even when symptoms are quiet.
The contrast shows that alarm features change the pathway before any question of metaplasia arises.
Where the exam tries to catch you
Examiners set several traps around diagnosis and surveillance.
- Trap: diagnosing Barrett oesophagus from a columnar-lined segment alone. Correct: without goblet cells on biopsy the metaplasia is not intestinal, so the diagnosis is not confirmed.
- Trap: assuming proton pump inhibitors prevent progression of Barrett oesophagus. Correct: that benefit has not been clearly established, so the drug is used for symptom control rather than cancer prevention.
- Trap: blaming reflux for dysphagia with weight loss. Correct: dysphagia with weight loss means cancer until proven otherwise, not reflux.
- Trap: using simple surveillance for high-grade dysplasia. Correct: endoscopic therapy replaces simple surveillance in that setting.
In an Indian context, the question may ask about GERD in an obese patient, where weight reduction and lifestyle measures sit alongside acid suppression.
Frequently asked questions
What histological feature defines Barrett oesophagus?
Barrett oesophagus is defined by intestinal metaplasia on biopsy, showing goblet cells within the columnar-lined distal oesophagus. Columnar epithelium without goblet cells does not meet the histological criteria for the diagnosis.
Which symptoms should prompt endoscopy before starting a proton pump inhibitor for reflux?
Dysphagia, weight loss, anaemia, persistent vomiting and gastrointestinal bleeding are alarm features in gastro-oesophageal reflux disease that prompt endoscopy before empirical therapy. Age over 55 with new persistent reflux symptoms is also an indication for endoscopy in several guidelines.
How is the length of Barrett oesophagus recorded?
Barrett oesophagus length is recorded using the Prague classification, with the C value for circumferential extent and the M value for maximal extent. Both are measured from the gastro-oesophageal junction and guide surveillance and therapy decisions.
What endoscopic therapy treats high-grade dysplasia in Barrett oesophagus?
Radiofrequency ablation and endoscopic mucosal resection are the main endoscopic therapies for high-grade dysplasia in Barrett oesophagus. Focal lesions are resected first, and ablation then clears residual metaplasia where appropriate.