8. Barrett’s Oesophagus

📄 Definition

Barrett’s oesophagus is a premalignant condition where the normal squamous epithelium of the distal oesophagus is replaced by metaplastic columnar epithelium (intestinal metaplasia) due to chronic gastro-oesophageal reflux. It significantly increases the risk of oesophageal adenocarcinoma.

🛡️ Risk Factors (Mnemonic: BARRETT)

  • Barrett’s or oesophageal cancer in family

  • Age over 50

  • Reflux (chronic GORD symptoms ≥5 years)

  • Race – White ethnicity

  • Elevated BMI (central obesity)

  • Tobacco smoking

  • Truncal fat distribution (android obesity)

📋 Clinical Features (Mnemonic: GORD++)

Most cases are asymptomatic and diagnosed incidentally on OGD for GORD.

  • GORD symptoms: heartburn, regurgitation, dysphagia

  • Odynophagia (rare)

  • Reflux resistant to PPIs

  • Dyspepsia or chest discomfort

  • ++ = Associated risk of progression to dysplasia or carcinoma

⚠️ Red Flag Features (Mnemonic: ALARM55)

Refer for urgent upper GI endoscopy (OGD) if any of the following are present:

  • Anaemia (iron-deficiency)

  • Loss of weight (unintentional)

  • Anorexia

  • Recent-onset progressive dysphagia

  • Melaena or haematemesis

  • Age ≥55 with new-onset upper GI symptoms

Also refer if:

  • Male ≥50 with long-standing GORD + risk factors (e.g. central obesity, smoking)

🔬 Investigations

  • OGD with biopsy:

    • Seattle protocol (4-quadrant biopsies every 1–2 cm)

    • Confirms intestinal metaplasia with goblet cells

  • Histology: classify as

    • Non-dysplastic

    • Low-grade dysplasia (LGD)

    • High-grade dysplasia (HGD)

Management (Mnemonic: MAP)

🧭 Monitor (endoscopic surveillance)

  • Non-dysplastic: every 3–5 years

  • LGD: every 6–12 months or consider treatment if confirmed by two pathologists

  • HGD or early cancer: urgent endoscopic therapy

💊 Acid suppression

  • Long-term PPI therapy for all patients

  • Symptom control and may reduce dysplasia progression

Procedure (if dysplasia)

  • Radiofrequency ablation (RFA) – preferred for flat dysplasia

  • Endoscopic mucosal resection (EMR) – for nodular areas

  • Consider oesophagectomy for early cancer if endoscopic therapy not appropriate

❗ Complications (Mnemonic: CANCER)

  • Carcinoma (oesophageal adenocarcinoma)

  • Anaemia (chronic GI bleeding)

  • Need for lifelong surveillance

  • Complications of endoscopic treatment (strictures, bleeding)

  • Esophagitis (recurrent)

  • Reflux persists despite therapy

Last updated in line with NICE CKS: Dyspepsia – reflux and BSG Barrett’s Oesophagus surveillance guidelines
Published: May 2010 • Last updated: April 2023
Last reviewed: July 2025
PASSMAP ensures all content is NICE-aligned and reviewed for Physician Associate Registration Assessment (PARA) success.

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