Proton Pump Inhibitors
Acid suppression with proton pump inhibitors is the cornerstone of medical therapy for Barrett’s esophagus. Studies show these inhibitors result in consistent symptom relief. However, even at high doses, the result in either no regression of the Barrett’s segment or modest clinically insignificant regression. Proton pump inhibitors typically increase squamous islands in the Barrett’s segment, but biopsies taken from such islands typically show underlying intestinal metaplasia.
It is clear that symptom control with proton pump inhibitor therapy is not necessarily equivalent to normalization of esophageal acid exposure, even with the use of high doses. The mechanism underlying the failure of acid suppression in Barrett’s esophagus patients remains unknown. While there are no data to suggest that normalization of esophageal acid exposure decreases cancer risk in these patients, recent studies show that short-term normalization of intraesophageal acid exposure in Barrett’s esophagus patients decreases cellular proliferation and increases cellular differentiation. The implication of this finding is that adequate control of esophageal acid exposure could theoretically decrease the risk of cancer by decreasing cell proliferation rates. However, this remains unproven to date. Currently, it is unclear if Barrett’s patients should undergo routine 24-hour pH monitoring to assess the response to therapy. Clearly, the costs of such an approach would be substantial and patient acceptance of this would be problematic. Furthermore, the ability to act on this information in patients already receiving high doses of proton pump inhibitors is uncertain. Still other patients with Barrett’s esophagus are completely asymptomatic without any antisecretory therapy. It is unclear if these patients should be offered antisecretory therapy at all.
Antireflux Surgery
Antireflux surgery also effectively alleviates GERD symptoms in Barrett’s patients. However, regression of Barrett’s epithelium is uncommon. Some surgical enthusiasts suggest that antireflux surgery decreases the subsequent risk of developing esophageal cancer, by decreasing both acid and duodenogastric reflux. However, there are few studies that support this concept. Thus, while surgery provides an excellent means of symptom control in Barrett’s patients, it probably does not influence the natural history of Barrett’s esophagus. Furthermore, antireflux surgery is not necessarily a permanent solution as breakdown of the operation remains a problem even in the best of surgical hands.
Ablation Therapy
Ablation therapy of Barrett’s esophagus without dysplasia is achievable by a number of different techniques. However, ablation should be viewed as experimental only, and not offered to patients as part of routine clinical practice. It is unknown if this therapy reduces the already small risk of esophageal adenocarcinoma in Barrett’s esophagus. All ablation therapy techniques typically result in residual macroscopically invisible intestinal metaplasia beneath the neosquamous lining that can still result in subsequent cancer.
