Barrett’s esophagus

Barrett’s esophagus is associated with chronic gastroesophageal reflux (GERD) and reflux esophagitis. Long-term acid exposure induces metaplastic changes in distal esophageal mucosa. And the esophageal squamous epithelium is replaced by columnar and goblet cells (intestinal metaplasia).

Pathogenesis 

Chronic GERD → Increased acid exposure → Esophageal mucosal injury and squamous epithelial damage → Acute and chronic inflammatory changes → Reflux esophagitis → Recovery from damaged area involves metaplastic changes (Barrett’s esophagus) → Esophageal stem cells develop intestinal metaplasia (columnar and goblet cells) → Metaplasia may lead to dysplasia → Adenocarcinoma of the esophagus

Associated Risk Factors 

• GERD
• Obesity
• Men > Women

Clinical Presentation of Barrett’s esophagus 

• Heartburn
• Regurgitation
• Difficulty in swallowing

Diagnosis 

History of chronic GERD and clinical presentation

Upper GI Endoscopy 

Endoscopic examination shows tongues and patches of red, velvety mucosa extending upwards from the gastroesophageal junction. The normal esophageal mucosa looks smooth, pale, and pearly white.

Biopsy 

Gastric and intestinal metaplasia is present in mucosa above the gastroesophageal junction. The presence of goblet cells with mucous vacuoles is defining feature of intestinal metaplasia. Goblet cells stain pale blue by H&E stain.

Management 

GERD control

• Weight loss
• Head elevation during sleeping
• Proton pump inhibitors

Periodic surveillance endoscopy with biopsy to rule out dysplasia and adenocarcinoma

In case of Dysplasia / intramucosal carcinoma-

• Photodynamic therapy
• Radiofrequency ablation
• Endoscopic mucosectomy
• Surgical resection (esophagectomy)

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Case scenario

A 55-year-old man presented to a clinician with chief complaints of retrosternal pain and difficulty swallowing. The upper GI endoscopy reveals red velvety mucosa alternating with pearly white esophageal mucosa. Which of the following cells are likely to be present in a biopsy from abnormal red and velvety mucosa?

1. Keratinized stratified squamous epithelium
2. Ciliated columnar epithelium
3. Goblet cells with mucous vacuoles
4. Cuboidal Epithelium

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