What is the management and treatment for Barrett's esophagus?

Management and Treatment of Barrett's Esophagus

The management of Barrett's esophagus requires a structured approach based on the presence of dysplasia, with endoscopic surveillance being the cornerstone for non-dysplastic Barrett's and endoscopic treatment being recommended for dysplastic Barrett's esophagus to prevent progression to esophageal adenocarcinoma. 1

Initial Management and Patient Education

• Offer a clinical consultation to newly diagnosed patients to discuss cancer risk, surveillance plans, and symptom control 1
• Provide verbal and written information about the diagnosis, treatment options, and patient support groups 1
• After each surveillance procedure, provide an endoscopy report with a lay summary of findings 1

Symptom Control

• Follow NICE guidelines on interventions for gastroesophageal reflux disease (GORD) 1
• Optimize acid suppression therapy with proton pump inhibitors (PPIs) like omeprazole 2
• Do not offer anti-reflux surgery specifically to prevent progression to dysplasia or cancer 1
• Do not offer aspirin to prevent progression to esophageal dysplasia and cancer 1

Surveillance Strategies

Non-dysplastic Barrett's Esophagus

• For Barrett's <3 cm without intestinal metaplasia (IM): Repeat endoscopy with quadrantic biopsies to confirm diagnosis; if IM remains absent, discharge from surveillance 1
• For Barrett's <3 cm with IM: Endoscopic surveillance every 3-5 years 1
• For Barrett's ≥3 cm: Endoscopic surveillance every 2-3 years 1

Dysplastic Barrett's Esophagus

• Indefinite for dysplasia: Optimize acid-suppressant medication and repeat endoscopy in 6 months; if no definite dysplasia is found, follow non-dysplastic surveillance protocol 1
• Low-grade dysplasia (LGD): Confirm diagnosis with two GI pathologists; offer radiofrequency ablation if confirmed on two separate endoscopies 1
• High-grade dysplasia (HGD): Perform expert high-resolution endoscopy to detect visible abnormalities; all cases should be reviewed by a second GI pathologist 1

Treatment of Dysplasia and Early Cancer

High-grade Dysplasia

1. Offer endoscopic resection of visible lesions as first-line treatment 1
2. Offer endoscopic ablation of any residual Barrett's esophagus after endoscopic resection 1
3. For flat HGD without visible lesions, manage with endoscopic ablative technique (radiofrequency ablation preferred due to better safety profile) 1

Early Adenocarcinoma

• T1a adenocarcinoma: Offer endoscopic resection as first-line treatment, followed by ablation of residual Barrett's esophagus 1
• T1b adenocarcinoma: For patients fit for surgery and at high risk of cancer progression, offer oesophagectomy 1
• For T1b adenocarcinoma patients unfit for surgery, consider radiotherapy (alone or with chemotherapy) 1

Multidisciplinary Approach

• All patients with dysplasia or early cancer should be discussed at a specialist MDT for oesophago-gastric cancer 1
• The team should include an interventional endoscopist, upper GI cancer surgeon, radiologist, and GI pathologist 1

Follow-up After Treatment

• Offer endoscopic follow-up to people who have received endoscopic treatment for Barrett's esophagus with dysplasia 1
• Offer endoscopic follow-up to people who have received endoscopic treatment for stage 1 esophageal adenocarcinoma 1
• Offer endoscopic follow-up to people who have received radiotherapy for T1b esophageal adenocarcinoma 1

Important Caveats and Pitfalls

• Visible lesions should be considered malignant until proven otherwise 1
• Given the management implications of dysplasia diagnosis, all cases of suspected dysplasia should be reviewed by a second GI pathologist 1
• The addition of p53 immunostain to histopathological assessment may improve diagnostic reproducibility of dysplasia 1
• For T1b adenocarcinomas with involvement of the second submucosal layer or beyond (T1b sm2-sm3), endoscopic therapy should not be considered curative 1
• Low-grade dysplasia has a variable natural history, with 75% of cases not being confirmed on later biopsies, highlighting the importance of pathologist confirmation 3

By following this structured approach to Barrett's esophagus management, clinicians can optimize early detection of dysplasia and cancer, potentially reducing mortality from esophageal adenocarcinoma while minimizing unnecessary interventions for patients at lower risk.