From the Guidelines
For patients with newly diagnosed Barrett's esophagus, the recommended follow-up schedule depends on the presence of dysplasia, with surveillance intervals ranging from every 3-5 years for non-dysplastic cases to more frequent monitoring for low-grade and high-grade dysplasia, as outlined in recent guidelines 1.
Key Considerations
- The presence of dysplasia significantly influences the follow-up schedule, with low-grade dysplasia typically requiring confirmation and then annual surveillance, and high-grade dysplasia necessitating more aggressive management with endoscopic eradication therapy followed by close surveillance 1.
- Endoscopic surveillance should include four-quadrant biopsies every 1-2 cm throughout the Barrett's segment, along with biopsies of any visible abnormalities, to ensure thorough assessment and early detection of potential progression to esophageal adenocarcinoma 1.
- Patients should be maintained on proton pump inhibitors to control reflux symptoms and potentially reduce the risk of progression, although the primary goal of surveillance is early detection and intervention rather than prevention of dysplasia or cancer through medical therapy alone 1.
Surveillance Intervals
- For non-dysplastic Barrett's esophagus, surveillance every 3-5 years is generally recommended, balancing the risk of progression against the risks and costs associated with endoscopy 1.
- Low-grade dysplasia typically requires follow-up EGD in 6-12 months to confirm the diagnosis, followed by annual surveillance, reflecting the increased risk of progression to high-grade dysplasia or esophageal adenocarcinoma in these patients 1.
- High-grade dysplasia necessitates immediate and more aggressive management, often with endoscopic eradication therapy, followed by close surveillance every 3 months for at least a year, then annually, due to the high risk of underlying or developing esophageal adenocarcinoma 1.
Recent Guidelines
Recent guidelines from the National Institute for Health and Care Excellence (NICE) 1 emphasize the importance of endoscopic surveillance and eradication therapy in managing Barrett's esophagus, particularly for patients with dysplasia, highlighting the need for a personalized approach based on the presence and grade of dysplasia, as well as the patient's overall risk profile and preferences.
From the Research
Follow-up Schedule for EGD in Patients with Newly Diagnosed Barrett's Esophagus
The recommended follow-up schedule for endoscopic gastro-duodenoscopy (EGD) in patients with newly diagnosed Barrett's esophagus varies depending on the presence and grade of dysplasia.
- For patients with no dysplasia, surveillance endoscopy is recommended at an interval of every 2 to 3 years 2.
- For patients with low-grade dysplasia, surveillance endoscopy every 6 months for the first year is recommended, followed by yearly endoscopy if the dysplasia has not progressed in severity 2.
- For patients with high-grade dysplasia, two alternatives are proposed after the diagnosis has been confirmed by an expert gastrointestinal pathologist: intensive endoscopic surveillance until intramucosal cancer is detected at an interval of every 3-6 months, or esophageal resection 2.
Importance of Confirmatory EGD
Confirmatory EGD is important in patients with newly diagnosed Barrett's esophagus to exclude the presence of dysplasia.
- A study found that 8.2% of patients with newly diagnosed Barrett's esophagus had dysplasia on confirmatory EGD, with a higher rate of dysplasia detection in patients with long-segment Barrett's esophagus (29.7%) compared to those with short-segment Barrett's esophagus (0.95%) 3.
- The yield of confirmatory EGD is greater in patients with long-segment Barrett's esophagus, suggesting that this group may benefit from more frequent surveillance 3.
Risk of Esophageal Cancer
The risk of esophageal cancer in patients with Barrett's esophagus is low, with an annual risk of approximately 0.25% for patients without dysplasia and 6% for patients with high-grade dysplasia 4.
- A study found that the incidence of esophageal adenocarcinoma in patients with Barrett's esophagus was 1/220 patient-years of total follow-up, with a mean number of endoscopies performed for surveillance of 2.4 per patient 5.
- Endoscopic eradication therapy with radiofrequency ablation significantly reduces the frequency of progression to cancer for patients with high-grade dysplasia 4.
Management of High-Grade Dysplasia
High-grade dysplasia in Barrett's esophagus can be managed with endoscopic eradication therapy, which is the treatment of choice for high-grade dysplasia and an option for low-grade dysplasia 4, 6.
- A study found that surgical resection of the esophagus is curative in patients who progress to cancer during regular surveillance, and that surveillance endoscopies with biopsy is a valid and safe follow-up strategy for Barrett's patients who have high-grade dysplasia without cancer 6.