What is the diagnosis and treatment of Barrett's esophagus?

From the Guidelines

Barrett's esophagus should be diagnosed and managed according to the most recent guidelines, which recommend endoscopy with biopsy showing intestinal metaplasia for diagnosis, and treatment with proton pump inhibitors (PPIs) and lifestyle modifications, with surveillance endoscopy and endoscopic treatments for dysplastic cases. The condition is classified as non-dysplastic, low-grade dysplasia, or high-grade dysplasia based on cellular changes. According to the National Institute for Health and Care Excellence (NICE) guidance on monitoring and management of Barrett's oesophagus and stage I oesophageal adenocarcinoma 1, individuals with Barrett’s oesophagus need to be fully informed about the implications of this diagnosis and the benefits and risks of monitoring strategies.

Diagnosis and Classification

• Diagnosis requires endoscopy with biopsy showing intestinal metaplasia
• Classification is based on cellular changes: non-dysplastic, low-grade dysplasia, or high-grade dysplasia
• The British Society of Gastroenterology guidelines on the diagnosis and management of Barrett's oesophagus recommend the use of a p53 immunostain to improve diagnostic reproducibility of dysplasia 1

Treatment and Management

• Treatment focuses on managing underlying GERD with PPIs such as omeprazole 20-40mg daily, pantoprazole 40mg daily, or esomeprazole 40mg daily
• Lifestyle modifications are essential, including weight loss, avoiding meals within 3 hours of bedtime, elevating the head of the bed, and avoiding trigger foods
• Surveillance endoscopy is recommended every 3-5 years for non-dysplastic Barrett's, every 6-12 months for low-grade dysplasia, and every 3 months for high-grade dysplasia
• For dysplastic Barrett's, endoscopic treatments like radiofrequency ablation, endoscopic mucosal resection, or cryotherapy may be indicated, as recommended by the American Gastroenterological Association medical position statement on the management of Barrett's esophagus 1

Endoscopic Treatments

• Radiofrequency ablation (RFA) is effective in achieving complete eradication of intestinal metaplasia and reducing progression to esophageal cancer, as shown in a randomized sham-controlled trial 1
• Endoscopic mucosal resection (EMR) is a valuable diagnostic and therapeutic procedure for patients with dysplasia associated with visible mucosal irregularities in Barrett’s esophagus
• Cryotherapy is not currently recommended due to limited data on its efficacy and safety

Surgery

• Surgery (esophagectomy) is typically reserved for cases with invasive adenocarcinoma or extensive high-grade dysplasia that cannot be managed endoscopically, as recommended by the NICE guidance on monitoring and management of Barrett's oesophagus and stage I oesophageal adenocarcinoma 1

From the Research

Diagnosis of Barrett's Esophagus

• The diagnosis of Barrett's esophagus is established with a combination of endoscopic recognition, targeted biopsies, and histologic confirmation of columnar metaplasia 2.
• Endoscopy plays an important role in the identification, diagnosis, and treatment of Barrett's esophagus, with biopsy specimens obtained from tissue of presumed Barrett's esophagus or an irregular Z line confirming metaplastic glandular mucosa and permitting evaluation of dysplastic or neoplastic changes 3.
• The histologic hallmark of intestinal metaplasia is required to confirm diagnosis, with the presence of goblet cells being a key feature 4.
• Narrow band imaging is among several tools used in the esophagus to improve detection of Barrett's esophagus and associated dysplasia 5.

Treatment of Barrett's Esophagus

• Specific therapy for Barrett's esophagus should lead to the complete regression of the metaplastic epithelium with adequate squamous reepithelialization 6.
• Proton pump inhibitors have been shown to be superior to H2 blockers in the treatment of patients with severe esophagitis, but do not appear to lead to a significant regression of Barrett's epithelium 6.
• Antireflux surgery does not significantly and consistently lead to a reduction in length or disappearance of the Barrett's mucosa, and does not prevent the development of dysplasia and its progression to carcinoma 6.
• Endoscopic thermal modalities, such as laser and photodynamic therapy, have allowed for endoscopic mucosal ablation, with long-term results being more encouraging when this mucosal ablation is associated with aggressive antireflux therapy (medical or surgical) 6.

Surveillance and Management

• The surveillance of patients with Barrett's esophagus relies on histologic evaluation of dysplasia, with significant pathologic limitations and diagnostic variability in evaluating the presence and grading of Barrett's esophagus dysplasia 4.
• All Barrett's esophagus dysplasia samples should be reviewed by an expert gastrointestinal pathologist to confirm the diagnosis 4.
• Close interaction between gastroenterologists and pathologists is essential to ensure proper evaluation of endoscopic biopsies in order to optimize the surveillance and clinical management of patients with Barrett's esophagus 4.