Barrett’s Oesophagus

Barrett’s oesophagus refers to metaplasia of the oesophageal epithelial lining, whereby normal stratified squamous epithelium is replaced by simple columnar epithelium.

The prevalence ranges from 0.5-2% in the Western world. Around 10% of patients with gastro-oesophageal reflux disease (GORD) will have already developed Barrett’s oesophagus by the time they seek medical attention.

In this article, we shall look at the causes, clinical features and management of Barrett’s oesophagus.


Metaplasia is the abnormal reversible change of one cell type to another. In Barrett’s oesophagus, the normal stratified squamous layer is replaced by simple columnar epithelium.

The vast majority of cases are caused by chronic gastro-oesophageal reflux disease. The epithelium of the oesophagus becomes damaged by the reflux of gastric contents, resulting in a metaplastic transformation. This in turn increases the risk of developing dysplastic and neoplastic changes.

The distal oesophagus is most commonly affected. On endoscopy, the oesophagus appears red and velvety, with some preserved pale squamous islands. Diagnosis relies on biopsy demonstrating the presence of simple columnar epithelium within the oesophagus.

Fig 1 - Barrett's oesophagus at the GOJ, showing gastric acinar metaplasia on the left and oesophageal stratified squamous epithelium on the right

Fig 1 – Barrett’s oesophagus at the GOJ, showing gastric acinar metaplasia on the left and oesophageal stratified squamous epithelium on the right

Risk Factors

The risk factors for developing Barrett’s oesophagus include:

  • Caucasian
  • Male
  • >50yrs of age
  • Smoking
  • Obesity
  • Hiatus hernia
  • Family history of Barrett’s oesophagus

Clinical Features

The typical presentation of Barrett’s oesophagus is a history of chronic gastro-oesophageal reflux disease. Features include retrosternal chest pain, excessive belching, odynophagia, chronic cough and hoarseness.

Always check for red flag symptoms (dysphagia, weight loss, early satiety, malaise and loss of appetite) for any underlying malignancy (although these are late symptoms of malignancy, so may be absent). Examination will be unremarkable in cases of solely Barrett’s oesophagus with no further complications.


Barrett’s oesophagus is a histological diagnosis. Patients who undergo endoscopy for chronic or resistant GORD (or to exclude malignancy) should have a biopsy taken of the oesophageal epithelium and sent for histological analysis.

The length (squamo-columnar to gastro-oesophageal junction) and degree of dysplasia are important in classification, and should be recorded on each endoscopy:

  • A length <3cm is classed as short segment and ≥3cm is classified as a long segment
  • Grades of dysplasia include no dysplasia, indefinite for dysplasia, low grade dysplasia and high grade dysplasia

Once a patient is diagnosed with Barrett’s oesophagus, they require lifelong monitoring via endoscopy.

Fig 2 - The endoscopic appearance of Barrett's oesophagus.

Fig 2 – The endoscopic appearance of Barrett’s oesophagus.


All patients with Barrett’s oesophagus should be commenced on a proton-pump inhibitor (typically high dose and twice daily). Any medication that affects stomach defences (such as NSAIDs) should be stopped. In addition, the patient should be provided with lifestyle advice to reduce the acidic stimulus on the squamous cells (the driver of the metaplastic change.

The major risk of Barrett’s oesophagus is progression to adenocarcinoma. Therefore, all patients with confirmed Barrett’s oesophagus must undergo regular routine endoscopy (Table 1)

A recent study compared anti-reflux surgery with medical treatment in GORD patients with Barrett’s oesophagus. It found that a higher percentage (15.4%) of patients who underwent anti-reflux surgery had eventual regression of Barrett’s oesophagus, compared with medically managed patients (1.9%).




No dysplasia Every 2 to 5 years
Low grade dysplasia Every 6 months Repeat endoscopy with quadrantic biopsies every 1cm. There is no consensus on long-term surveillance in this group.
High grade dysplasia Every 3 months If a visible lesion is present, endoscopic ablation with mucosal resection (EMR) or radiofrequency ablation should be considered

Table 1 – Surveillance endoscopy for Barrett’s oesophagus


Premalignant lesions are resected with endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD), which limits the need for oesophagectomy.

If carcinoma is discovered on routine endoscopy, then oesophagectomy may be indicated. Adenocarcinomas detected on routine screening for Barrett’s oesophagus are typically early-stage lesions and have a better prognosis than those discovered outside of any screening program

Key Points

  • Barrett’s oesophagus is a metaplasia of the oesophageal epithelial lining and is a purely histological diagnosis
  • Severity is determined by length and degree of dysplasia
  • Most cases will just undergo surveillance endoscopy, however higher grade lesions may warrant endoscopic mucosal resection or other surgical intervention


Question 1 / 3
Which of the following correctly defines Barrett’s Oesophagus?


Question 2 / 3
A patient is diagnosed with Barrett’s Oesophagus and biopsy's show no evidence of dysplastic cells. How often should the patient undergo routine surveillance endoscopy?


Question 3 / 3
Which of these is not a risk factor for


Further Reading

The effect of antireflux surgery on esophageal carcinogenesis in patients with barrett esophagus: a systematic review
Chang EY et al., Annals of Surgery

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