What is the recommended therapy for Barrett's esophagus?

From the Guidelines

The recommended therapy for Barrett's esophagus is primarily focused on managing dysplasia, with endoscopic resection and ablation being the preferred treatment options for high-grade dysplasia, and radiofrequency ablation being considered for low-grade dysplasia, as stated in the most recent guidance from the National Institute for Health and Care Excellence (NICE) 1. The goal of therapy is to prevent progression to esophageal adenocarcinoma by controlling acid reflux and removing dysplastic tissue when present. Key aspects of management include:

• Aggressive acid suppression with proton pump inhibitors (PPIs) to control symptoms of gastro-oesophageal reflux, with the dose reviewed regularly to assess for side effects and prevent potential long-term side effects 1
• Endoscopic surveillance, with frequency determined by the degree of dysplasia, to monitor for progression to dysplasia or cancer
• Endoscopic resection and ablation for high-grade dysplasia, with radiofrequency ablation being considered for low-grade dysplasia 1
• Lifestyle modifications, including weight loss, elevating the head of the bed, avoiding meals within 3 hours of bedtime, and eliminating trigger foods, to reduce symptoms and prevent progression Regular endoscopic surveillance is necessary for all Barrett's patients, with the frequency of surveillance determined by the degree of dysplasia, and the presence of any visible lesions or other risk factors. It is essential to note that the current evidence does not support the use of aspirin to prevent progression to oesophageal dysplasia and cancer, and that the use of molecular biomarkers to confirm the histologic diagnosis of dysplasia or as a method of risk stratification for patients with Barrett’s esophagus is not recommended at this time 1. In patients with confirmed low-grade dysplasia, endoscopic eradication therapy should be considered, with the goal of achieving complete eradication of intestinal metaplasia, and patients who have achieved complete eradication of intestinal metaplasia should undergo surveillance every year for 2 years and then every 3 years thereafter to detect recurrent intestinal metaplasia and dysplasia 1.

From the Research

Therapy for Barrett's Esophagus

The recommended therapy for Barrett's esophagus varies depending on the presence and grade of dysplasia.

• For patients with nondysplastic Barrett's esophagus, endoscopic surveillance is recommended every 3-5 years 2, 3.
• For patients with low-grade dysplasia, endoscopic ablative therapy is recommended, although endoscopic surveillance continues to be an acceptable alternative 2, 3.
• For patients with high-grade dysplasia, endoscopic ablative therapy is recommended 2, 3.
• For patients with Barrett's esophagus and early cancer, endoscopic therapy consisting of resection and ablation can be effective 4.

Endoscopic Surveillance

Endoscopic surveillance is an important part of managing Barrett's esophagus.

• The American College of Gastroenterology recommends endoscopic surveillance for patients with known Barrett's esophagus 5, 3.
• The frequency of surveillance depends on the presence and grade of dysplasia, as well as other risk factors 5, 3.
• Endoscopic surveillance can help detect dysplasia and early cancer, allowing for early intervention and potentially improving outcomes 5, 3.

Medical Therapy

Medical therapy, such as proton pump inhibitors, can help control reflux symptoms in patients with Barrett's esophagus.

• However, the role of medical therapy in preventing neoplastic progression is unclear 4, 6.
• Proton pump inhibitors can be used to help control reflux symptoms, but their use should be individualized based on patient needs and risk factors 6.

Other Considerations

Other considerations in the management of Barrett's esophagus include:

• The use of biomarkers and advanced endoscopic imaging techniques is not routinely recommended 2.
• Postablation endoscopic surveillance intervals are recommended to monitor for recurrence of Barrett's esophagus 2.
• The management of Barrett's esophagus should be individualized based on patient needs and risk factors, and should involve a multidisciplinary approach 3, 4.