Barrett's esophagus

As Barrett 's esophagus - after the British surgeon Norman Rupert Barrett, who described the disease in 1957 - refers to a metaplastic transformation of the epithelium of the esophagus. Obsolete is the disease as Endobrachyösophagus ( gr ένδον inside, βραχύς short, οίσοφάγος esophagus ) refers. Barrett's esophagus is a complication of gastroesophageal reflux disease, so the partial running back of acidic stomach contents into the esophagus. The conversion of squamous epithelium in leads to an inner esophageal shortening, hence the Greek name derives.

The formation of an esophageal peptic ulcer on the metaplastic mucosa is called Barrett's syndrome or Allison Johnstone syndrome.

Definition

In the strict clinical sense only a circular ( the entire circumference of the esophagus detected ) is metaplasia of the Z line extends ( the physiological transition from disk in epithelium ) in the direction of the oral cavity, called Barrett 's esophagus. One distinguishes the kurzsegmentigen Barrett 's esophagus ( so-called short -segment Barrett 's esophagus ) with a length to 3 cm and the langsegmentigen Barrett 's esophagus ( so-called long- segment Barrett 's esophagus ) with a length about 3 cm here.

Epidemiology

The number of gastroscopy patients who had Barrett's esophagus, varied according to the study, between one and four percent. Men are affected twice as often as women. Significant risk factors include increased alcohol and nicotine. In addition, depending on the excitation localization, both a protective and disease- promoting influence of Helicobacter pylori infection discussed.

Pathophysiology and Classification

Normally, the esophagus is lined in their entire extent of stratified squamous epithelium. Repeated or chronic inflammation, often as a result of gastroesophageal reflux, this epithelium can convert to high prismatic epithelium with goblet cells, as is typical for the intestinal mucosa. The mucous membrane may, however, in principle mimic various epithelia of the gastrointestinal tract ( cardia - type fundus - type parietal cells, intestinal type with villi and goblet cells ). As a cause of an error control in the regeneration of the mucous membrane is considered according to erosive esophagitis. The epithelium is indeed more resistant to the acid and pepsin load, it carries the risk of further degeneration ( dysplasia) in itself. In addition, it tends to ulcerate ( Barrett's ulcer) and training of strictures.

The metaplasia forms in most cases directly at the gastroesophageal junction from, so at the final segment of the esophagus, just before it empties into the stomach. The conversion of Epitheltyps is definitely and forms are not or only partially with adequate treatment of reflux back.

The macroscopic classification (corresponding directly visible at endoscopy changes ) using the " Prague classification ". Two dimensions are combined: first, the length of the changes that extend over the entire circumference of the esophagus ( circumferrentielle metaplasia ) is recorded in centimeters together with the name "c" and second, the additional, usually tongue-shaped streamers are also in centimeters indicated by the label " m" for maximum extension. For example, a finding " C8M9 " an annular metaplasia to 8 cm and a maximum length dimension of the metaplasia of 9 cm.

Development of carcinoma

The risk for the development of adenocarcinoma ( the so-called Barrett's carcinoma ) on the bottom of a Barrett 's esophagus is about 0.5-1.5 % per patient- year for dysplasia at 4.5 %. This is therefore a so-called precancerous lesion. In recent years, the risk of malignant transformation of Barrett's esophagus, however, was corrected continuously downward. Only recently, a Danish study comes to the conclusion that the cancer risk is only 0.12% per patient-year.

Specific measures

For detection of Barrett's esophagus regular endoscopic follow up is warranted. The opinions about the necessary frequency is controversial. Metaplasia, which capture only the distal two to three inches (short -segment Barrett ), need to be not checked routinely, because the risk of development of carcinoma is low according to some experts. Any further metaplasia (long -segment Barrett; Endobrachyösophagus in the strict clinical sense ) should first be subjected to a year and from the third year of a biennial inspection by esophago - gastroscopy. Confocal endomicroscopy offers high security in the diagnosis of neoplastic changes. In cases of confirmed higher grade dysplasia, the affected segment is resected.

In recent years, with early malignant changes in Barrett 's esophagus ( so-called high-grade intraepithelial neoplasia and adenocarcinoma limited to the mucosa ) has established endoscopic therapy. In the first place, especially endoscopic resection is mentioned. With this method the tumor is first drawn and then resected with a noose during a normal endoscopic examination. Endoscopic therapy is now well studied and also the long-term results demonstrate their effectiveness and safety. The advantage over conventional surgery, which comes with a mortality rate of 5-20 % and a complication rate of 30-50 % associated, is the low load on the patients without serious complications. Malignant changes grow deeper into the layers of the wall of the esophagus ( in the submucosa ), however, a surgical therapy in an experienced surgical center (more than 20 Speiseröhrenresektionen per year) should be carried out, since in this case the risk of lymph node metastasis ( 30% ) is given.

Literature and sources

  • Dietel, Dudenhausen, Suttorp (eds): Harrison's Internal Medicine, 2.Band, McGraw -Hill, ABW Science Publishing (2003)
  • Shaheen NJ, Crosby MA, Bozymski EM, Sandler RS. (2000) Is there publication bias in the reporting of cancer risk in Barrett 's esophagus? In: Gastroenterology, 119 ( 2) :333 -8.
  • Rahden BHA, Stein HJ (2007) Barrett 's esophagus and Barrett 's carcinoma. In: Curr GERD Rep 1:125-32.
  • Pech O, May A, Rabenstein T, Ell C. Endoscopic resection of early oesophageal cancer. In: Gut 56 (2007) 1625th
  • Pech O, Behrens A, May A, neighbor L, Gossner L, Rabenstein T, Manner H, Guenter E, Huijsmans J, Vieth M, Stolte M, Ell C ( 2008). Long - term results and risk factor analysis for recurrence after curative endoscopic therapy in 349 patients with high-grade intraepithelial neoplasia and mucosal adenocarcinoma in Barrett 's esophagus. In: Gut 57 (9 ) :1200 - sixth
  • Ell C, May A, Pech O, Gossner L, Guenter E, Behrens A, neighbor L, Huijsmans J, Vieth M, Stolte M. (2007) Curative endoscopic resection of early esophageal adenocarcinomas ( Barrett 's cancer ). In: Gastrointest Endosc. 65 3
  • Pech O, Gossner L, May A, Rabenstein T, Vieth M, Stolte M, Berres M, Ell C. (2005) Long - term results of photodynamic therapy with 5 - aminolevulinic acid for superficial Barrett 's cancer and high-grade intraepithelial neoplasia. In: Gastrointest Endosc. 62:24-30.
  • Birkmeyer JD, Siewers AE, Finlayson EV, Stukel TA, Lucas FL, Batista I, Welch HG, Wennberg DE. (2002) Hospital volume and surgical mortality in the United States. In: N Engl J Med 346 (15) :1128-37
  • Birkmeyer JD, Stukel TA, Siewers AE, Goodney PP, Wennberg DE, Lucas FL. (2003) Surgeon volume and operative mortality in the United States. In: N Engl J Med 349 (22) :2117-27
Norman Barrett Gastroenterology (journal) Gut (journal)
50133
de