Chronic GERD Complications: Understanding Barrett’s Esophagus and When to Get Screened

Chronic heartburn isn’t just annoying-it can be a warning sign of something more serious. If you’ve had acid reflux for more than five years, especially if it happens several times a week, your esophagus may be changing in ways you can’t see or feel. That change is called Barrett’s esophagus, and it’s the body’s attempt to heal itself after years of stomach acid burning the lining. But this healing comes with a hidden risk: it can lead to esophageal cancer.

What Exactly Is Barrett’s Esophagus?

Barrett’s esophagus happens when the normal tissue lining your esophagus-soft, pink, and made of squamous cells-gets replaced by a different kind of tissue: columnar cells that look more like the lining of your intestine. This is called intestinal metaplasia. It was first identified in 1950 by British pathologist Norman Barrett, and since then, we’ve learned it’s not just a change in appearance-it’s a biological shift that increases cancer risk.

This isn’t something that happens overnight. It takes at least 10 years of regular acid reflux for the damage to accumulate enough to trigger this transformation. About 5.6% of people in the U.S. have Barrett’s esophagus, but among those with long-term GERD, the rate jumps to 10-15%. Men are three times more likely to develop it than women, and White men over 50 with a history of smoking or obesity face the highest risk.

The scary part? Barrett’s esophagus doesn’t cause new symptoms. If you’re already dealing with heartburn, regurgitation, trouble swallowing, or chest pain, you might assume those are just part of living with GERD. But those same symptoms are often the only clues you have. There’s no blood test, no scan, no simple way to detect it without an endoscopy.

How Is It Diagnosed?

Diagnosis requires an upper endoscopy-a thin, flexible tube with a camera is passed down your throat to look at your esophagus. If the lining looks unusually salmon-colored instead of pale pink, doctors suspect Barrett’s. But color alone isn’t enough. They take small tissue samples-usually 12 to 24 biopsies-using the Seattle protocol, which means sampling every 1 to 2 centimeters along the affected area.

These samples are reviewed by a pathologist to confirm intestinal metaplasia. Once confirmed, the condition is graded based on whether abnormal cells (dysplasia) are present:

• Non-dysplastic Barrett’s esophagus (NDBE): No precancerous changes. Most common.
• Indefinite for dysplasia: Changes are unclear. Needs follow-up.
• Low-grade dysplasia (LGD): Mild cell abnormalities. Higher risk.
• High-grade dysplasia (HGD): Severe abnormalities. Close to cancer.

High-grade dysplasia carries a 6-19% chance of turning into cancer each year. That’s why catching it early matters.

Who Should Be Screened?

Not everyone with heartburn needs an endoscopy. Screening isn’t recommended for people with occasional reflux. But if you’re a man over 50 with chronic GERD-meaning symptoms at least three times a week for more than five years-and you have one or more of these risk factors, screening is advised:

• White race
• Obesity (especially belly fat)
• Smoking history
• Family history of Barrett’s or esophageal cancer

Women and younger men without these risk factors are generally not screened because the risk is low enough that the cost and potential risks of endoscopy outweigh the benefits. But if you’re a woman with long-term GERD and multiple risk factors, talk to your doctor. Guidelines aren’t one-size-fits-all.

Here’s the hard truth: most people don’t get screened until it’s too late. Studies show 68% of patients had symptoms for over five years before being diagnosed. Many thought their heartburn was just ‘bad indigestion’ and didn’t seek help. Others saw doctors who didn’t recognize the need for endoscopy.

What Happens After Diagnosis?

If you’re diagnosed with non-dysplastic Barrett’s esophagus, your main goal is to stop the acid from causing more damage. That means:

• High-dose proton pump inhibitors (PPIs), like omeprazole 40mg twice daily
• Weight loss-aim for a BMI under 25
• Avoiding trigger foods: caffeine, chocolate, fatty meals, spicy food
• Not eating within three hours of bedtime
• Elevating the head of your bed by 6-8 inches

But here’s something many don’t realize: controlling your heartburn doesn’t always mean you’ve stopped the acid from damaging your esophagus. Studies using pH monitors show that even when symptoms improve, acid reflux can still be happening. That’s why symptom relief ≠ tissue protection.

For surveillance, the American College of Gastroenterology recommends:

• NDBE: Endoscopy every 3-5 years
• LGD: Confirm with a second pathologist, then endoscopy every 6-12 months
• HGD: Don’t wait-treat it

For high-grade dysplasia, endoscopic treatments are now standard. Radiofrequency ablation (RFA) uses heat to destroy the abnormal tissue. Cryotherapy uses freezing. Both have success rates of 90-98% in eliminating dysplasia. Many patients are cured within months. One patient at Mayo Clinic had HGD cleared after six months of RFA and hasn’t had a recurrence in five years.

The Big Problem: Too Many Unnecessary Procedures

Only about 5% of people with Barrett’s esophagus ever develop cancer. That means 95% of those undergoing regular endoscopies are being monitored for a risk that won’t happen to them. Each endoscopy carries small risks-bleeding, perforation, sedation complications-and costs hundreds to thousands of pounds. In the U.S., over $1.2 billion is spent annually on Barrett’s surveillance.

Doctors are now trying to find better ways to tell who’s truly at risk. New tools like the TissueCypher Barrett’s Esophagus Assay analyze tissue for molecular markers that predict cancer progression. In a 2021 study, it had a 96% negative predictive value-meaning if the test says low risk, you’re very unlikely to develop cancer in the next three years. Medicare now covers it.

Another promising area is DNA methylation testing. A $2.4 million study in Texas (2023-2026) is testing whether certain gene changes can identify the small group of patients who need aggressive monitoring-and spare the rest from endless scopes.

What You Can Do Now

If you’ve had daily heartburn for over five years, especially if you’re a man over 50, overweight, or a smoker:

• Don’t wait for symptoms to get worse.
• Ask your GP for a referral to a gastroenterologist.
• Get an endoscopy if recommended.
• Start lifestyle changes now-even if you’re not diagnosed.

Even if you’re diagnosed with non-dysplastic Barrett’s, you’re not powerless. Lifestyle changes can reduce your risk of progression. Weight loss alone can cut acid reflux by half. Quitting smoking reduces cancer risk by 40% over five years.

And if you’re already on PPIs, don’t assume they’re doing everything. Ask your doctor about 24-hour pH monitoring. It’s the only way to know if your medication is truly suppressing acid-not just masking symptoms.

Final Thought: Knowledge Is Protection

Barrett’s esophagus is silent until it’s not. By the time cancer shows up, survival rates drop below 20%. But if caught early-before dysplasia, or even with low-grade changes-most people can avoid cancer entirely.

It’s not about fear. It’s about awareness. If you’ve lived with chronic GERD for years, you’ve already paid the price in discomfort. Don’t let the next step be a diagnosis of cancer. Ask for screening. Make the changes. Take control before it’s too late.