What are the treatment guidelines for Barrett's esophagus?

From the Guidelines

The treatment of Barrett's esophagus should follow a stepwise approach based on disease severity, with endoscopic resection and radiofrequency ablation being the preferred treatment options for high-grade dysplasia, as recommended by the National Institute for Health and Care Excellence (NICE) guidance 1.

Treatment Approach

The treatment approach for Barrett's esophagus is based on the severity of the disease. For non-dysplastic Barrett's esophagus, the mainstay of treatment is proton pump inhibitors (PPIs) to control acid reflux and prevent progression.

• Endoscopic surveillance is recommended every 3-5 years for non-dysplastic Barrett's esophagus.
• For low-grade dysplasia, confirmed by two pathologists, options include continued surveillance every 6-12 months or endoscopic eradication therapy, typically radiofrequency ablation (RFA) 1.

High-Grade Dysplasia Treatment

For high-grade dysplasia or early intramucosal carcinoma, endoscopic eradication is strongly recommended, using endoscopic mucosal resection for visible lesions followed by RFA for remaining Barrett's tissue 1.

• After successful treatment, patients should continue PPI therapy indefinitely and undergo surveillance endoscopy initially every 3 months, then every 6-12 months.

Lifestyle Modifications

Lifestyle modifications are important for all patients, including:

• Weight loss if overweight
• Elevation of the head of the bed
• Avoiding meals within 3 hours of bedtime
• Smoking cessation These recommendations aim to control acid reflux, which drives the metaplasia-dysplasia-carcinoma sequence, and to detect or eradicate dysplastic changes before they progress to invasive esophageal adenocarcinoma.

Radiofrequency Ablation

Radiofrequency ablation (RFA) has been shown to be effective in treating Barrett's esophagus with low-grade dysplasia, with a high proportion of patients achieving reversion to normal-appearing squamous epithelium 1.

• RFA therapy for patients with high-grade dysplasia reduces progression to esophageal cancer, as shown in a randomized sham-controlled trial 1.

From the Research

Treatment of Barrett's Esophagus

The treatment of Barrett's esophagus is based on several guidelines, including:

• Medical treatment with proton pump inhibitors (PPIs) to control symptoms and reduce acid exposure 2, 3
• Endoscopic treatment, including radiofrequency ablation (RFA) and endoscopic mucosal resection, for patients with high-grade dysplasia or intramucosal carcinoma 4, 3
• Surveillance endoscopy and biopsy to monitor for dysplasia and cancer 5, 6

Endoscopic Eradication Therapy

Endoscopic eradication therapy is recommended for patients with Barrett's esophagus and:

• High-grade dysplasia 5, 4
• Low-grade dysplasia 5
• Intramucosal carcinoma 4

Surveillance Intervals

Surveillance intervals are recommended based on the degree of dysplasia:

• No dysplasia: 3-year interval 6
• Low-grade dysplasia: annual endoscopy until no dysplasia is recognized 6
• High-grade dysplasia: intense surveillance every 3 months or intervention 6

Role of Proton Pump Inhibitors

Proton pump inhibitors (PPIs) may have a cancer-protective effect in Barrett's esophagus by:

• Eliminating chronic esophageal inflammation 2
• Decreasing esophageal exposure to acid 2
• Reducing the risk of dysplasia and cancer 2, 3

Other Treatment Options

Other treatment options for Barrett's esophagus include:

• Laparoscopic surgery, partial or total fundoplication, for patients who are indolent to PPIs and endoscopy or have progressive disease 3
• Chemoprevention with PPIs, which appears to be cost-effective 2