What is the management approach for Barrett's esophagus?

From the Guidelines

The management of Barrett's esophagus should prioritize endoscopic resection of visible lesions as first-line treatment for high-grade dysplasia, followed by endoscopic ablation of any residual Barrett's esophagus, as recommended by the most recent guidelines 1. The goal of treatment is to control acid reflux, surveil for dysplasia, and treat any dysplastic changes to prevent progression to esophageal adenocarcinoma. Key aspects of management include:

• Controlling acid reflux with proton pump inhibitors (PPIs) such as omeprazole, esomeprazole, or pantoprazole to reduce acid exposure and prevent progression.
• Lifestyle modifications, including weight loss, elevating the head of the bed, avoiding meals before bedtime, and eliminating trigger foods.
• Surveillance endoscopy with intervals determined by dysplasia status: every 3-5 years for non-dysplastic Barrett's, every 6-12 months for low-grade dysplasia, and immediate intervention for high-grade dysplasia.
• Endoscopic treatments like radiofrequency ablation, endoscopic mucosal resection, or cryotherapy for dysplastic Barrett's, with the choice of treatment depending on the grade of dysplasia and the presence of visible lesions. These approaches are supported by recent guidelines and studies, including the National Institute for Health and Care Excellence (NICE) guidance on monitoring and management of Barrett's esophagus and stage I oesophageal adenocarcinoma 1, and are aimed at reducing the risk of esophageal adenocarcinoma and improving patient outcomes.

From the Research

Management Approach for Barrett's Esophagus

The management of Barrett's esophagus (BE) involves a combination of endoscopic surveillance, medical therapy, and endoscopic treatment. The goal of management is to prevent the progression of BE to esophageal adenocarcinoma and to detect dysplasia or cancer at an early stage.

Diagnosis and Surveillance

• The diagnosis of BE is made if the distal esophagus is lined with columnar epithelium with a minimum length of 1 cm (tongues or circular) containing specialized intestinal metaplasia at histopathological examination 2.
• The European Society of Gastrointestinal Endoscopy (ESGE) recommends varying surveillance intervals for different BE lengths, with more frequent surveillance for longer segments of BE 2, 3.
• The ESGE also recommends that patients with BE and a maximum extent of ≥ 10 cm should be referred to a BE expert center for surveillance endoscopies 2, 3.

Medical Therapy

• The mainstay of medical therapy for BE is normalization of esophageal acid exposure with proton pump inhibitors (PPIs) 4.
• The optimal dose of PPIs required to achieve adequate intraesophageal acid suppression in patients with BE is unknown, but once daily dosing may be sufficient for most patients 4.

Endoscopic Treatment

• Endoscopic eradication therapy is recommended for patients with BE and high-grade dysplasia or early cancer 5, 3.
• Endoscopic ablation treatment is recommended for BE with confirmed low-grade dysplasia on at least two separate endoscopies, both confirmed by a second experienced pathologist 3.
• Complete eradication of all remaining Barrett epithelium by ablation after endoscopic resection of visible abnormalities containing any degree of dysplasia or esophageal adenocarcinoma is recommended 3.

Expert Centers

• BE expert centers should meet certain criteria, including an annual case load of ≥ 10 new patients undergoing endoscopic treatment for high-grade dysplasia or early carcinoma per BE expert endoscopist, and multidisciplinary meetings with gastroenterologists, surgeons, oncologists, and pathologists to discuss patients with Barrett's neoplasia 2.
• Patients with BE and a maximum extent of ≥ 10 cm should be referred to a BE expert center for surveillance endoscopies 2, 3.

Follow-up

• The first endoscopic follow-up after successful endoscopic eradication therapy (EET) of BE should be performed in an expert center 3.
• Careful inspection of the neo-squamocolumnar junction and neo-squamous epithelium with high definition white-light endoscopy and virtual chromoendoscopy during post-EET surveillance is recommended to detect recurrent dysplasia 3.