Answered by: J. Patrick Waring, M.D., Digestive Healthcare of Georgia, Atlanta, Georgia

If no Barrett's was found, do I need another endoscopy?

Question
I underwent an endoscopic exam about 1 year ago and was diagnosed with GERD (but not Barrett's). Do I need another endoscopy? How can I tell if there has been damage to the esophagus?
Answer

This is a very common question in my practice. It is important for someone with chronic heartburn symptoms to have an endoscopy. The most important thing to look for is Barrett’s esophagus, a change in the lining of the esophagus that is associated with an increased cancer risk. The endoscopist will also be looking for esophagitis, damage to the lining of the esophagus. The endoscopist may see a hiatal hernia or other anatomic abnormalities.

Patients with Barrett’s esophagus should be enrolled in a surveillance program to look for signs of abnormal tissue (dysplasia) or cancer. This is a very slow growing cancer and endoscopies are usually done every 3 years. Patients with esophagitis should have a repeat endoscopy to demonstrate healing. Occasionally, when the esophagitis is healed, one can see Barrett’s esophagus.

Patients with no esophagitis and no Barrett’s esophagus on their initial endoscopy should not need a repeat exam unless there has been a major change in symptoms. The reason is that if heartburn symptoms are well controlled, it is uncommon to develop Barrett’s esophagus.

More importantly, it is extremely uncommon to develop Barrett’s esophagus and then develop esophageal cancer. If there is no history of esophagitis and your heartburn is controlled with your diet and medications, you can be fairly certain that there is no significant ongoing esophageal injury.

Does Barrett's go away?

Question
Two years ago I was diagnosed with Barrett’s esophagus. I had another endoscopy last year and this time they said it was reflux esophagitis. I was wondering: Does Barrett’s disappear?
Answer
Barrett’s esophagus is a change in the lining of the lower esophagus that can develop as a result of acid reflux. Patients with Barrett’s esophagus have a small increased risk for developing esophageal cancer in that tissue. During an endoscopy, the physician sees a change in the color of the tissue at the lower end of the esophagus. If the biopsies of that tissue show intestinal cells, then the diagnosis of Barrett’s esophagus is made. It would be nice if there were a clear demarcation of the normal and abnormal tissue.
However, that is not always the case. Barrett’s tissue tends to develop sporadically in some patients. It is not at all uncommon for the doctor to take a biopsy of tissue that looks abnormal, but turns out to be normal. But if the biopsy had been taken just a few millimeters away, it would be consistent with Barrett’s esophagus. This may occur up to 20% of the time in people with small segments of Barrett’s mucosa.

There is still some controversy, as some physicians believe that Barrett’s esophagus can regress, or disappear. However, the above explanation seems much more plausible. The bottom line is that you have Barrett’s esophagus. The most recent biopsies were fine. Your risk for developing esophageal cancer remains very low, but since it is higher than the general population, you should continue to have an endoscopy every three years.

Is there any diet advice for Barrett’s esophagus?

Question
I have GERD and was recently diagnosed with Barrett’s esophagus. I am working with my doctor to keep it under control. Is there any diet advice for Barrett’s esophagus? Also, I used to love eating chocolate but now avoid it as it provokes heartburn. Is it OK to eat carob as a substitute for chocolate?
Answer

It is interesting that there are very few rigorously performed scientific studies that demonstrate which foods worsen GERD. Some foods have been shown to increase gastric acid production, while others relax the lower esophageal sphincter (LES), the muscle at the bottom end of the esophagus.

Chocolate has been shown to lower the LES pressure and increase acid reflux for a short period of time after ingestion. Carob has never been formally studied in adults. However, it has been shown that infants have less reflux when they are given thicker formulas. When carob bean gum is used as the thickener it decreases acid reflux. It would appear that carob may be safe for heartburn sufferers, as a chocolate alternative.

I like to use a common sense approach when making dietary recommendations. It is important to avoid overeating. Large meals distend the stomach and increase gastric acid production. Patients with GERD should not eat late, as eating within 2–3 hours of bedtime increases acid reflux at night. Specific foods such as caffeine, citrus juice, sodas, chocolate, fried foods, fatty foods, peppermints, tomato sauces, or alcohol may aggravate reflux.

However, it seems impractical to completely avoid all of these foods. Patients should avoid overindulging in these foods. They should also avoid foods on this list (and any others not on the list) that make their heartburn worse.

The common sense approach may need to be modified for some patients. Patients with Barrett’s esophagus do not always feel the heartburn when they are refluxing. The same is true for some patients with asthma, chronic cough, or those with laryngeal pharyngeal reflux (LPR). While there is no special diet for these patients, a more vigilant approach to avoiding the foods mentioned above is warranted.

Adapted from IFFGD Publication: Barrett’s Esophagus and Diet and IFFGD Publication: Do I Need Another Endoscopy? by J. Patrick Waring, MD, Digestive Healthcare of Georgia, Atlanta, GA.

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