Barrett's esophagus: treatment

It is known that Barrett's esophagus can occur in patients with progression of GERD, but its development is possible even in patients who do not suffer from this disease. The main principles of drug treatment for GERD patients are known, which, as our experience has shown, can be used in the treatment of patients with GERD complicated by Barrett's esophagus. The search continues for the most optimal treatment options for such patients, whose goal is to eliminate not only the clinical manifestations of GERD, but also the elimination of all morphological characters considered characteristic of Barrett's esophagus, and, accordingly, improvement of the quality of life of patients. It is often assumed that the treatment of Barrett's esophagus depends mainly on the presence and extent of dysplasia, but it is not always possible to "stop" the progression of dysplasia, and its reverse development.

[1], [2], [3], [4]

Drug treatment Barrett's esophagus

The main pharmacological treatment of Barrett's esophagus is aimed at inhibiting acid formation in the stomach and eliminating (reducing the frequency and intensity) of gastroesophageal reflux. Preference in the treatment of patients is given to proton pump inhibitors (omeprazole, pantoprazole, lansoprazole, rabeprazole or esomeprazole) used in the treatment of patients, most often in standard therapeutic doses (20 mg, 40 mg, 30 mg, 20 mg and 20 mg, respectively, 2 times, respectively in a day). It must be remembered that with the help of proton pump inhibitors, 100% inhibition of acid in the stomach can not be achieved.

With resistance to proton pump inhibitors, reaching 10% in some populations, treatment of Barrett's esophagus should use antagonists of histamine H2 receptors (ranitidine or famotidine, respectively, at 150 mg and 20 mg twice daily). In such cases, the use of ranitidine or famotidine at higher doses in the treatment of GERD patients with Barrett's esophagus is fully justified during the period of marked worsening of the patients for 1-2 weeks, then the doses of the drugs gradually decrease as they recover.

Inhibition of acid formation in the stomach leads to a decrease in it not only the total volume of acid, but also the acidification of the contents of the duodenum, which, in turn, helps inhibit the release of proteases, especially trypsin. However, the pathological effect of bile acids (salts) on the mucosa of the esophagus remains. At the same time, prolonged inhibition of acid formation in the stomach by inhibitors of the proton pump leads to a decrease in the total volume of the stomach contents due to a decrease in the release of acid, and, correspondingly, a higher concentration of bile acids (due to a decrease in "dilution" with hydrochloric acid). During this period, bile acids (salts) acquire the main importance in the development of adenocarcinoma of the esophagus. In such cases, treatment of Barrett's esophagus should use ursodeoxycholic acid (ursosan), which has a positive effect on biliary reflux gastritis and biliary reflux esophagitis (one capsule before bedtime).

For absorption of bile acids in the treatment of patients, if necessary, it is additionally expedient to use also nonabsorbable antacid preparations (phosphalugel, neoglossum Neo, maalox, etc.) 3-4 times a day an hour after ingestion. This will absorb the bile acids that come with duodenogastric reflux into the stomach, and then into the esophagus.

For faster elimination of heartburn and / or chest pain and / or in the epigastric region, and if there is a symptom of rapid saturation, Barrett's esophagus treatment should include the use of prokinetics (domperiodone or metoclopramide), respectively, 10 mg 3 times a day for 15-20 minutes before meals. If patients have symptoms associated with increased sensitivity of the stomach to stretching (the appearance of severity, overflow and bloating in the epigastric region, occurring during or immediately after meals), it is recommended that patients also include enzyme preparations that do not contain bile acids (pancreatin , penzital, kreon, etc.).

The disappearance of clinical symptoms, possible in patients with GERD with Barrett's esophagus as a result of ongoing treatment, is not an indicator of complete recovery. Therefore, treatment of Barrett's esophagus primarily with proton pump inhibitors should be continued: in order to reduce financial costs in the future - copies of omeprazole (Pleom-20, ultop, romisec, gastrozole, etc.) or copies of lansoprazole (lancide, lancaz, helicol), as well as copies of pantoprazole (sanpras), copies of ranitidine (ranisan, zantak, etc.) or famotidine (famosan, gastrosidine, quamater, etc.).

The use of ranitidine in high doses (600 mg per day) in the treatment of patients with GERD with Barrett's esophagus is justified (due to the high probability of side effects) only with individual intolerance to famotidine (60-80 mg per day) or proton pump inhibitors. Conducted therapy allows you to eliminate for a period of time the symptoms of GERD in most patients, others - to reduce their effectiveness and frequency of occurrence. In some patients, as a result of the treatment (with the disappearance of endoscopic signs of esophagitis, healing of ulcers and erosions of the esophagus), there are no symptoms considered characteristic of GERD; in other patients, the presence of reflux is not accompanied by pain and heartburn in view of the reduced pain sensitivity of the esophagus.

Given the possibility of various factors leading to the appearance of Barrett's esophagus, it is advisable to periodically alternate drugs inhibiting acid formation in the stomach with drugs that have an enveloping and cytoprotective effect protecting the mucous membrane of the esophagus from aggressive action of bile acids and pancreatic enzymes, for example, the use of sucralfate gel (sucrat gel) for 1.0 g an hour before breakfast and in the evening before going to bed for at least 6 weeks. However, the possibilities of such treatment for patients with Barrett's esophagus are not yet clear, although the use of this drug in the treatment of certain patients with GERD gives a certain positive effect. For the present, treatment of the Barrett's esophagus with proton pump inhibitors is more common (in some cases in combination with prokinetics). However, the opposite may be the argument that adenocarcinoma of the esophagus appears after elimination of gastroesophageal reflux and sufficient inhibition of hydrochloric acid, which is possible, however, only for a short time after the abolition of medicinal preparations. Apparently, it is necessary to have a sufficiently long medication treatment for patients.

It is relatively rare, even if there is a permanent treatment of the Barrett's esophagus by inhibitors of the proton pump (with dynamic observation), during histological examination of the biopsy material, it is possible to identify areas of "creeping" of multilayered squamous epithelium of the esophagus into a single-layered cylindrical epithelium of the stomach or intestine in the terminal section of the esophagus, indicates the effectiveness of the treatment. Unfortunately, "antireflux" therapy does not affect the more or less significant extent of the sites of metaplastic cylindrical epithelium in the esophagus, which is revealed in endoscopic studies (with targeted biopsies), and consequently the risk of adenocarcinoma of the esophagus does not decrease.

Adenocarcinoma of the esophagus may also appear after the removal of pathological changes in the mucous membrane of the esophagus visible through the usual endofibroscope. It is important to periodically conduct a dynamic examination of patients with Barrett's esophagus. There are various proposals on the timing of the control examinations of such patients with mandatory esophagoscopy with targeted biopsy and subsequent histological examination of the biopsy material obtained from the terminal section of the esophagus - respectively, regularly 1-2-3-6 months or one year. Such an observation, in our opinion, should be quite active on the part of the physician: some patients successfully treated for GERD (with Barrett's esophagus identified), during the subsequent follow-up checkups with good health (in the absence of clinical signs of reflux esophagitis) is not very eager agree (or refuse at all) to re-clinico-endoscopic examination, especially in those cases where patients have reduced pain sensitivity (the presence of gastroesophageal reflux re to accompanied by the appearance of pain and heartburn in the chest and / or in the epigastric region) or the survey is conducted more frequently than 2 times per year.

[5], [6], [7],

Barrett's esophagus surgery

Periodically in the literature, in connection with the increase in the frequency of precancerous and malignant changes in the foci of intestinal metaplasia of Barrett's esophagus, the question of possible surgical treatment of patients is discussed. When surgical treatment of Barrett's esophagus is advisable:

• the probability of occurrence of adenocarcinoma of the esophagus, in some patients, with the appearance of distant metastases;
• difficulties in the early diagnosis of adenocarcinoma of the esophagus, including with the use of X-ray, endoscopic and histological methods of examining the materials of targeted esophagobiopsy, especially in invasive cancer; in addition, dysplasia may not be detected and because of insufficient accuracy of the biopsy and a small amount of material obtained for histological examination;
• the need for periodic control endoscopic examination with multiple targeted biopsies;
• known difficulties in the morphological interpretation of the data obtained.

When surgical treatment of Barrett's esophagus is impractical:

1. the initial erroneous interpretation of the morphological changes in the mucosa, regarded as dysplasia, and later as a consequence of reactive changes regressing under the influence of "antireflux" therapy, is possible;
2. the possibility of regression of epithelial dysplasia of the esophagus mucosa in the treatment of patients with Barrett's esophagus under the influence of "antireflux" therapy is known;
3. The probability of developing adenocarcinoma of the esophagus is not observed in all patients;
4. the appearance of adenocarcinoma of the esophagus is possible only 17-20 years after its primary detection;
5. in some patients, even with a high degree of dysplasia, adenocarcinoma of the esophagus does not develop;
6. there is no tendency to increase the extent of metaplasia foci in some patients, despite the progression of GERD;
7. The question of the most rational surgical treatment of patients with Barrett's esophagus has not yet been fully resolved;
8. there is a possibility of occurrence of operational and postoperative, including fatal complications (up to 4-10%);
9. in some patients, the presence of contraindications to surgical treatment, associated with concomitant diseases; refusal of some patients from surgical treatment.

Considering Barrett's esophagus as one of the complications of GERD, it should be noted that Nissen fundoplication remains the most common operation in the treatment of such patients. Realization of Nissen fundoplication allows most patients to eliminate such symptoms of GERD as eructations and heartburn (at least in the nearest postoperative period), but this operation is unlikely to prevent the appearance of Barrett's esophagus.

There have been attempts to repeatedly perform laser photocoagulation (for this purpose, an argon laser is usually used) and electrocoagulation with the help of high-frequency currents of the centers of metaplastic epithelium, the terminal section of the esophagus (including treatment of patients in combination with antisecretory therapy). However, the effectiveness of this method is still unclear and whether such treatment can prevent the development of adenocarcinoma of the esophagus. In itself, the appearance of a corrosive scar after laser therapy is a risk factor for adenocarcinoma of the esophagus. It did not justify itself in the metaplastic epithelium of the mucosa of the esophagus, both electrocoagulation and photodynamic therapy.

In recent years, the question of carrying out endoscopic resection of small pathological foci of the Barrett's esophagus, including in combination with photodynamic therapy, is sometimes considered.

A single point of view on the treatment of patients with a high degree of dysplasia has not yet been adopted. There is also no consensus on surgical treatment of patients with Barrett's esophagus with a high degree of dysplasia, considered as the most dangerous in terms of transformation into cancer.

The radical operation is resection of the distal esophagus and cardia of the stomach to patients with Barrett's esophagus identified. However, how extensive is this operation? This question also needs to be clarified.

Given the age and condition of specific patients, Barrett's esophagus treatment in each case is individually, including taking into account the data of dynamic monitoring of their condition.

[8], [9]