Dr.Danny Cheung's presentation.

What is Barrett's, this is when the normal (squamous) oesophageal lining is replaced by a metaplastic columnar lining.

Who gets Barrett's. You are 12 times more likely to be diagnosed with Barrett's Oesophagus than members of the general public if you suffer from long standing acid reflux. Some other results show that being Caucasian increases the chances x 9, being male x 3, being over 50 x 3, being obese x 2 and smoking x 1.5 times.

Why is it important to diagnose Barrett's Oesophagus. Around 1 to 2 people will develop Barrett's at some time in their life, ther is a 1 in 200 chance of these people developing oesophageal ardenocarcinoma per year. This means that 1 to 2 people out of 20,000 people per year may develop Oesophageal Adenocarcinoma from the onset of Barrett's Oesophagus. Surveillance of the Barrett's Oesophagus by endoscopy every 2 -5 years gives us the chance of spotting these changes earlier and gives us the chance of a better ouycome from treatment. Early diagnosis gives the chance of treatment by Radiofrequency Ablation, where a probe on the endoscope uses heat to burn off the affected tissue or Endoscopic Mucosal Resection where the mucous surface of the oesophagus is removed by endoscopic surgery. Both of these methods are very successful if the tumour is found at a very early stage.

So should we screen everyone? The British Society of Gastroenterology guidelines on the diagnosis and management of Barrett's oesophagus state that "screening with endoscopy is not feasible or justified for an unselected population with gastro-oesophageal reflux symptoms".

So who should we screen, the Moses study suggests that if you are over 50 or have a family history of Upper GI cancers and suffer from the new onset of any of the following symptoms, increased difficulty in digesting food and drink, persistent strong pains at the top of your stomach, persistent heartburn and acid reflux lasting more than three weeks, persistent vomiting or you regurgitate food & drink, you have to take medicines such as Gaviscon or Rennies etc. on a regular basis or you suffer from unexpected or unexplained weight loss then your G.P should recommend you for an endoscopy.

The Moses study has four GP surgeries involved in the study who invite people who show these symptoms to take part in trials. 30 patients have been recruited and screened to date. These patients are invited for a one off trans-nasal endoscopy, and blood test for genetic screening. They are also asked to fill in a questionnaire to identify risk factors.

The benefits of trans-nasal endoscopy over the standard endoscopy are that it is much more comfortable for the patient. The endoscope is much smaller than the standard model, less than half the diameter. This means that the endoscope can be passed through the nose rather than the mouth and this by-passes the back of the tongue so there is no gagging effect. It also means that less sedation is required and no mouth guard is needed. This means that the patient can talk to the doctor while the procedure is taking place. The disadvantages are that smaller biopsies are taken and that the less robust equipment is not suitable for general use.

Barrett's - the future.

The Boss trial. A trial is being carried out at several centres that involves 3,400 patients with Barrett's Oesophagus. 1.700 of these are having endoscopic surveillance every 2 years while the remaining 1,700 have endoscopy at need, this is to discover the effectiveness of regular checks. These trials will be followed up for 10 years and are due to complete in 2022.

Genes linked with Barrett's are Chromosome 6 and Chromosome 16.

Barrett's - the future (probably).

Screening will be linked to the risk factors as shown earlier plus the results of genetic testing. A number of non endoscopy options are being trialled for Barrett's, these include a cytosponge a rough sponge similar to a nylon scourer enclosed in a dissolvable capsule attached to a fine thread. The patient swallows the capsule which dissolves and the sponge expands. It is then drawn back through the gullet picking up surface tissue from the lining of the oesophagus.

The cytosponge

Another option is the Pillcam, a camera the size of a large size capsule that is swallowed and sends a series of images to a receiver which is carried by the patient as it passes through the digestive system. These images are then viewed by specialist doctors and nurses. The disadvantage is that there is no control over the direction of the pillcam lens once it has been swallowed. Both of these items are of course single use only!

The small group of us who could actually make it to this meeting found this information invaluable in our quest to raise awareness of Upper GI cancers, I only wish more of you could have been there, especially as Dr. Cheung's wife thanked us for our participation in the Moses research project by baking two beautiful cakes for us to share. A wonderful Victoria sponge and a fruit cake that contained cherries and apricots. These cakes did not go to waste. I didn't even get any to take home.