Primary Motility  Disorders of the  Esophagus
 The Esophageal
 Mucosa
 The
 Esophagogastric  Junction
 Barrett's
 Esophagus

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OESO©2015
 
Volume: The Esophagogastric Junction
Chapter: Esophageal columnar metaplasia (Barrett s esophagus)
 

Treatments

Are proton pump inhibitors alone able to induce regression in the length of Barrett's esophagus?

R.E. Sampliner (Tucson)

Proton pump inhibition therapy has become the mainstay of the treatment of Barrett's esophagus (BE). The response to therapy has often been judged by measuring the length of Barrett's mucosa at endoscopy ­ the distance from the incisors to the proximal margin of continuous Barrett's epithelium is subtracted from the distance from the incisors to the end of the esophagus [1]. The latter is judged by the end of the tubular organ, the endoscopic lower esophageal sphincter "pinch" and/or the proximal margin of the hiatal hernia folds. There are three published series reporting 74 patients treated for one year and 58 patients treated for at least two years using omeprazole 20 and 40 mg and lansoprazole 60 mg daily [2-4]. Although the majority of patients develop squamous islands in Barrett's esophagus, only one patient had apparent complete regression of BE. An additional 101 patients treated with omeprazole 20 mg, 40 mg or 80 mg daily for 2 to 4 years have been reported in abstract form (Table I) [5-9].

The mean change in the length of Barrett's mucosa in all but one of these trials was less than 1 cm. Length is clearly an inadequate assessment of the surface area of BE given the frequency of an irregular squamo-columnar junction and the development of squamous islands. One group assessed the area of Barrett's and reported a significant decrease [5]. An ideal technique for a more accurate assessment of the impact of therapy on the area of BE would be "quantitative endoscopy" [10] (and page 999). This technique utilizes computer software to create two-dimensional maps to calculate the area of Barrett's.

These trials have not titrated the dose of proton pump inhibitor to ensure normalization of 24-hour esophageal acid exposure. Patients with BE may require more than conventional doses to achieve normalization of esophageal acid exposure. In eight patients treated with 60 mg lansoprazole daily an average of 5.7 years with documented normalization of esophageal acid exposure (mean time pH ¾ 4: 0.8%, range 0-3.5%), there was a mean decrease in the length of Barrett's esophagus of only 0.5 cm - not a significantly greater decrease than in patients lacking esophageal acid control [11]. The interim conclusion based on the proton pump inhibitor trials to date is that total regression of BE rarely occurs and clinically significant regression in the length is uncommon with pharmacologic therapy alone.
Table I. Long term proton pump inhibitor therapy

References

1. Sampliner RE, Garewal HS, Fennerty MB, Aickin M. Lack of impact of therapy on extent of Barrett's esophagus in 67 patients. Dig Dis Sci 1990;35:93-96.

2. Gore S, Healey CJ, Sutton R, Eyre-Brook IA, et al. Regression of columnar lined (Barrett's) oesophagus with continuous omeprazole therapy. Aliment Pharmacol Ther 1993;7:632-628.

3. Sampliner RE. Effect of up to three years of high dose lansoprazole on Barrett's. Am J Gastroenterol 1994;89:1844-1848.

4. Neumann CS, Iqbal TH, Cooper BT. Long term continuous omeprazole treatment of patients with Barrett's esophagus. Aliment Pharmacol Ther 1995;9:451-454.

5. Weinstein WM, Lieberman DA, Lewin KJ, Weber LJ, et al. Omeprazole-induced regression of Barrett's esophagus: a 2 year randomized, controlled double blind trial. Gastroenterology 1996;110:A294.

6. LeRhun M, Boyer J, Goldfain D, Robaszkiewicz M, et al. Long term omeprazole effects on Barrett's mucosa. Gastroenterology 1996;110:A174.

7. Shaffer RT, Francis J, Carrougher JG, Kadakia SC. Effect of omeprazole on Barrett's epithelium after 3 years of therapy. Esoph Gast Duod Dis 1996;110:A255.

8. Bologna SD, Blumenkehl M, Wong D, Schubert TT. Barrett's esophagus response to long term omeprazole therapy. Gastrointest Endosc 1992;38:229.

9. Caldwell MTP, Byrne PJ, Walsh TN, Hennessy TPJ. A randomised trial on the effect of acid suppression on regression of Barrett's oesophagus. Gastroenterology 1996;110:A74.

10. Kim R, Baggott BB, Rose S, Shar AO, Mallory DL, et al. Quantitative endoscopy: precise computerized measurement of metaplastic epithelial surface area in Barrett's esophagus. Gastroenterology 1995;108:360-366.

11. Sharma P, Sampliner RE, Camargo P. Is esophageal pH control necessary in the treatment of Barrett's esophagus? Gastroenterology 1996;110:A256.

 


Publication date: May 1998 OESO©2015