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Forum Name: Gastroenterology Topics

Question: Barrett's, patulous/incompetent LES, 33 years old


 sunshine_sammi - Sat Dec 05, 2009 9:46 pm

Hello,
Just had an EGD with biopsy. It showed Barrett's esophagus, erosive changes in the esophagus due to acid reflux, and a patulous/incompetent lower esophageal sphincter with a 3 cm sliding hiatal hernia. Biopsies of the esophagus confirmed Barrett's esophagus with mild dysplasia. To make a long story short, have had GERD for 10 years or more. The GERD symptoms just went away after a few years so was not too concerned and did not know any better.

My first EGD was November 2009. I am a 33-year-old female. What led me to have an EGD was unexplained anemia and positive Hemoccult.

It will be January of next year before the GI doctor has an opening to see me. In the meantime, wondered what all this meant, especially the patulous/incompetent lower esophageal sphincter part. Can anyone elaborate? Also, should I ask the appointment scheduler to be seen sooner than January 2010?
 Dr. Besong Mangeb - Sun Dec 27, 2009 12:29 pm

The LES means lower esophageal sphincter.When we eat food, it moves from the mouth to the esophagus and then into the stomach. The LES acts like a guard that prevents anything that gets into the stomach from refluxing (moving back upward) into the esophagus. When the LES is patulous/incompetent , it can no longer effective prevent substances found in the stomach from from moving back into the esophagus. Therefore acid in the stomach and patially digested food can get back into the esophagus from the stomach giving rise to the condition you are having Gastro-esophageal Reflux Disease (GERD). Just be patient about your appointment you have with your the GI doctor. January is not late. What you need to worry about is you proper nutritional habits. Make sure you take iron supplements and vitamines for your anemia, stop alcohol consumption in case you are in it cos its going to worsen your symptoms, make sure you lay your head on a pillow when sleeping. Avoid heavy meals closed to bed time. Write back in case of any point you didn't understand.
 Dr.M.Aroon kamath - Sun Dec 27, 2009 11:38 pm

User avatar Hi,
Gastroesophageal reflux (GER) is fairly common and many persons may experience it once a while. But, Gastroesophageal reflux disease (GERD) is a more serious form of gastroesophageal reflux, and starts to affect one's life-style.

GERD can cause
- intestinal (heart-burn,&
- extra-intestinal symotoms (cough,wheezing,asthma.hoarsness,cough and halitosis etc).

Risk factors for Barrett’s esophagus are
- Age (the average age at diagnosis is 50, rare in children),
- male sex,
- Caucasian ethnicity and
- GERD symptoms of longer than 10 years duration.

Determining when the problem actually started is usually difficult. Most people diagnosed with Barrett’s have had it for 10 to 20 years before diagnosis.

There are no signs or symptoms specific for Barrett’s esophagus.

Although. people without GERD can have Barrett’s esophagus, it is found about three to five times more often in people who also have GERD. Barrett’s esophagus is more commonly seen in people who have more severe symptoms of GERD.

Barrett’s esophagus is the strongest independent risk factor of esophageal adenocarcinoma together with obesity.

Alarm symptoms such as dysphagia, losing weight without trying, blood in stool, persistent symptoms despite medical therapy, or new chest pain, warrant urgent evaluation.

Barrett’s esophagus simply means that a part of the esophageal 'squamous' mucosa gets converted to an 'intestinal type'. This is called as 'Metaplasia'. The epithelium in this mucosa may show changes on histology ('Dysplasia'), which can progress from 'low-grade' to 'high-grade' dysplasia and finally to a carcinoma.

Follow up endoscopy (endoscopic surveillence) is mandatory for patients with Barrett's (but, protocols may vary).
- For Barrett’s without dysplasia it is usually recommended at 3 years.
- For low-grade dysplasia, a repeat endoscopy in about 6 months may be advised.If the six-month endoscopy with multiple biopsies again shows only low grade dysplasia, the American College of Gastroenterology recommends that patients undergo annual endoscopy until there is no dysplasia.
- for high grade dysplasia, there are many types of management available
(High-grade dysplasia may be confused with early adenocarcinoma and poses a very high risk of progression at carcinoma).

Some of the management strategies for high grade dysplasia are...
- esophagectomy,
- endoscopic therapies to ablate the neoplastic tissue,
- endoscopic mucosal resection, and
- 'intensive endoscopic surveillance' wherein invasive therapies are withheld until biopsy specimens reveal adenocarcinoma.

There is no good evidence to indicate that surgical therapy provides regression in Barrett esophagus. Thus, antireflux surgery is not indicated for eradication of Barrett esophagus, but it certainly appropriate for patients who desire surgery for control symptoms of GERD.

Also,no antireflux therapy (including surgery) has been proved to decrease the risk of esophageal cancer.

Therefore, endoscopic surveillance should continue even after fundoplication (Open or laparoscopic).


The lower esophageal sphinter (LES) is one of the barriers for prevention of reflux.Disorders of LES are frequently associated with GER.
The LES may be
- hypotensive causing free reflux of acid into the esophagus.
- The LES barrier may be overwhelmed by increased intragastric pressure. This is often associated with impaired contraction of the diaphragmatic sphincter.
- LES may exhibit frequent reflex transient LES relaxations (TLESR). TLESR is a vagovagal inhibitory reflex(different from swallowing reflex and is akin to the belch reflex).

In your case, because you have a sliding hiatus hernia as well, the LES is likely to be incompetent any way, as the gasto-esophageal junction will be intra-thoracic and the intra-abdominal pressure can't act on it.

Of late, there have been an increasing interest in the role played by 'Longitudinal esophageal muscle contactions'. There is speculation that sustained acid reflux–induced longitudinal smooth muscle contractions can produce esophageal shortening that might play a part in the genesis of a sliding hiatus hernia. This hypothesis suggests that hiatal hernia may develop secondary to GER and then once developed may further aggravate the GERD.

Some isolated recent reports have suggested that there might be an increased risk of colonic adenomas and cancer in patients with Barrett's esophagus.

As you have unexplained anemia & occult blood in stool, certainly need an early re-evaluation.

Best wishes!

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