Diagnosis and treatment of Barrett's oesophagus. A general survey

Barrett's oesophagus is an acquired condition with columnar metaplasia of t he distal oesophagus. This condition represents the most serious consequenc e of chronic gastro-oesophageal reflux as it is associated with an increase d incidence of oesophageal adenocarcinoma. Since the exact pathophysiology is not known, prevention is not possible. The diagnosis of Barrett's oesoph agus requires the presence of intestinal metaplasia in at least one biopsy specimen from the lower oesophagus. Barrett's oesophagus is considered a pr emalignant condition and some cases progress from dysplasia to invasive ade nocarcinoma. Medical or surgical antireflux treatment controls symptoms and oesophagitis, but Barrett's oesophagus remains. Patients are usually follo wed up by endoscopy for detection of dysplasia or early cancer. Several rep orts in the literature have assessed the effects of H2-blocker and proton p ump inhibitors treatment on Barrett's epithelium, but none has clearly docu mented a significant and consistent regression of the metaplastic epitheliu m. Even with high doses of proton pump inhibitors given for a prolonged per iod of time, it does not appear that a significant regression of Barrett's epithelium can be achieved. Various studies have assessed the effects of an tireflux surgery on the regression of columnar epithelium and dysplasia and its potential protective effect on the subsequent development of carcinoma . Overall, it appears from these reports that antireflux surgery, despite a dequate symptomatic results, does not significantly and consistently lead t o a reduction in length or disappearance of the Barrett's mucosa, and does not prevent the development of dysplasia and its progression to carcinoma. Recently, numerous reports have documented the regression of Barrett's muco sa by using various experimental techniques : these thermal therapies focus on the removal of the columnar epithelium with restoration of the squamous epithelium. Technological advances including laser and especially photodyn amic therapy have allowed for endoscopic mucosal ablation. Long-term result s are more encouraging when this mucosal ablation is associated with antire flux medical or surgical therapy. Currently, none of these approaches can o bviate the need for continued endoscopic surveillance; however the photodyn amic therapy seems to be a promising alternative in the future.