What are the management guidelines for patients with Barrett's esophagus?

Management Guidelines for Barrett's Esophagus

The management of Barrett's esophagus should follow a structured approach based on the 2024 NICE guidelines, including regular endoscopic surveillance with high-resolution white light endoscopy and Seattle protocol biopsies, with surveillance intervals determined by the presence and grade of dysplasia. 1

Diagnosis and Initial Management

• Barrett's esophagus is defined as a length of at least 1 cm of columnar epithelium in the esophagus, confirmed by histopathology 1
• For newly diagnosed patients:
  • Offer a clinical consultation to discuss cancer risk, surveillance plans, and symptom control 1
  • Provide verbal and written information about diagnosis, treatments, and support groups 1
  • Follow NICE guidelines for GORD management for symptom control 1

Endoscopic Surveillance Protocol

Technique

• Use high-resolution white light endoscopy with Seattle biopsy protocol 1
• Take 4-quadrant biopsies every 2 cm in non-dysplastic Barrett's 1
• Take 4-quadrant biopsies every 1 cm in patients with known/suspected dysplasia 1
• Separately submit biopsies of any mucosal irregularities 1
• Document findings using Prague classification and Paris classification (for visible lesions) 2
• Allow minimum 1-minute inspection time per cm of Barrett's length 2

Surveillance Intervals

Based on the most recent NICE guidelines 1:

1. Non-dysplastic Barrett's esophagus:

   • Surveillance intervals should be based on length and risk factors
   • For BE with maximum extent of 1-3 cm: every 5 years 2
   • For BE with maximum extent of 3-10 cm: every 3 years 2
   • For BE ≥10 cm: refer to expert center 2
   • Consider discontinuing surveillance at age 75 or if life expectancy <5 years 2

2. Indefinite for dysplasia:

   • Optimize acid-suppressant medication
   • Repeat endoscopy in 6 months
   • If no definite dysplasia found, follow non-dysplastic surveillance protocol 1

3. Low-grade dysplasia (LGD):

   • Confirm diagnosis by two pathologists 1
   • Offer radiofrequency ablation 1, 2
   • If not treated with ablation, surveillance every 6 months 1

4. High-grade dysplasia (HGD):

   • Refer to specialist MDT for oesophago-gastric cancer 1
   • Perform expert high-resolution endoscopy to detect visible abnormalities 1
   • Offer endoscopic resection of visible lesions as first-line treatment 1
   • Offer endoscopic ablation of any residual Barrett's after endoscopic resection 1

Management of Dysplasia and Early Cancer

Low-grade Dysplasia

• Offer radiofrequency ablation for confirmed LGD on two separate endoscopies, confirmed by a second pathologist 2
• If not treated with ablation, perform surveillance every 6 months initially 1

High-grade Dysplasia

• Offer endoscopic resection for visible lesions 1
• Offer ablation for flat HGD and residual Barrett's after resection 1, 2
• Consider p53 immunostain as an adjunct to improve diagnostic reproducibility 1

Stage 1 Esophageal Adenocarcinoma

• Offer endoscopic resection for staging 1
• For T1a adenocarcinoma:
  • Offer endoscopic resection as first-line treatment 1
  • Offer ablation of residual Barrett's after resection 1
• For T1b adenocarcinoma:
  • Low-risk (invasion ≤500μm, no lymphovascular invasion, well/moderate differentiation): consider endoscopic resection 2
  • High-risk (deeper invasion, lymphovascular invasion, poor differentiation): offer oesophagectomy if fit for surgery 1
  • Consider radiotherapy (alone or with chemotherapy) for high-risk patients not suitable for surgery 1

Post-treatment Follow-up

After endoscopic eradication therapy:

• First follow-up should be performed in an expert center 2
• Careful inspection of neo-squamocolumnar junction using high-definition white-light endoscopy 2
• Targeted biopsies of any suspicious areas 2
• For baseline HGD/EAC: follow-up at 1,2,3,4,5,7, and 10 years 2
• For baseline LGD: follow-up at 1,3, and 5 years 2

Prevention Strategies

• Do NOT offer aspirin to prevent progression to dysplasia/cancer 1
• Screen for cardiovascular risk factors for which aspirin therapy might be indicated 1
• Antireflux surgery is not more effective than medical therapy for cancer prevention 1

Important Caveats

1. Visible lesions should always be considered malignant until proven otherwise 1
2. Diagnosis of dysplasia should be confirmed by two gastrointestinal pathologists 1
3. Endoscopic surveillance has limitations with sampling error exceeding 95% using standard protocols 3
4. The incidence of adenocarcinoma in Barrett's esophagus is relatively low (1/220 patient-years) 4, but surveillance improves outcomes in patients with dysplasia 5
5. All patients with dysplasia or early cancer should be discussed at a specialist MDT including an interventional endoscopist, upper GI cancer surgeon, radiologist, and GI pathologist 1