What is the management approach for patients with Barrett's esophagus?

Management of Barrett's Esophagus

The management of Barrett's esophagus should be based on the degree of dysplasia, with endoscopic eradication therapy recommended for patients with confirmed high-grade dysplasia rather than surveillance alone, while patients without dysplasia should undergo regular endoscopic surveillance with appropriate biopsy protocols. 1

Diagnosis and Surveillance

Endoscopic Surveillance Protocol

• White light endoscopy is the standard for surveillance (strong recommendation) 2
• Biopsy protocol should follow the Seattle protocol:
  • For non-dysplastic Barrett's: 4-quadrant biopsies every 2 cm 2
  • For known/suspected dysplasia: 4-quadrant biopsies every 1 cm 2
  • Any mucosal irregularities should be biopsied separately 2
• Advanced imaging techniques (chromoendoscopy, confocal laser endomicroscopy) are not necessary for routine surveillance but may help guide biopsies in patients with known dysplasia 2

Surveillance Intervals

• Barrett's <3cm with intestinal metaplasia: every 3-5 years 1
• Barrett's ≥3cm: every 2-3 years 1
• Low-grade dysplasia: confirm with two GI pathologists before determining management 1
• High-grade dysplasia: refer to specialist center for endoscopic therapy 1

Treatment Approaches

Medical Management

• Proton pump inhibitors (PPIs) are first-line therapy for symptom control 1
• Standard PPI dosing is recommended for symptom management 2
• Higher doses of PPIs (beyond once daily) are not recommended solely for cancer prevention 2
• Antireflux surgery is not superior to medical therapy for preventing cancer progression 2
• Consider antireflux surgery for patients with poor response to PPIs 2

Endoscopic Eradication Therapy

• For high-grade dysplasia: endoscopic eradication therapy with radiofrequency ablation (RFA), photodynamic therapy (PDT), or endoscopic mucosal resection (EMR) is strongly recommended over surveillance 2
• For visible lesions: EMR is recommended to determine T stage 2
• For low-grade dysplasia: consider RFA after confirmation by two pathologists 1

Surgical Management

• Oesophagectomy should be performed in high-volume centers due to lower in-hospital mortality 2
• Surgical intervention is primarily indicated for invasive adenocarcinoma that has extended into submucosa 2
• No evidence supports one technique of oesophagogastrectomy over another 2

Important Clinical Considerations

Acid Suppression and Cancer Prevention

• Despite the theoretical benefit, there is insufficient evidence that acid suppression prevents progression to cancer 1, 3
• Studies show that patients with Barrett's esophagus may have persistent acid reflux despite PPI therapy and symptom control 4, 5
• Up to 62% of patients with Barrett's esophagus have abnormal intraesophageal pH profiles despite adequate symptom control on PPIs 4
• Nocturnal acid breakthrough is particularly common 5

Limitations of Treatment

• Regression of Barrett's metaplasia with medical or surgical therapy is often partial and inconsistent 3, 6
• Long-term studies (up to 6 years) with omeprazole 20 mg daily showed no significant shortening of Barrett's segment length, though squamous islands appeared in 55% of patients 6
• The goal of endoscopic eradication therapy is complete elimination of intestinal metaplasia, but regression may be incomplete 1
• Adenocarcinoma can develop under squamous epithelium in areas of apparent reversal after ablative therapy 1

Chemoprevention

• There is insufficient evidence to support the use of aspirin or NSAIDs solely for cancer prevention in Barrett's esophagus 2
• Screening for cardiovascular risk factors is warranted as cardiovascular deaths are more common than deaths from esophageal adenocarcinoma in these patients 2

Patient Education and Support

• All patients should receive verbal and written information about their diagnosis, cancer risk, and surveillance plans 1
• Patients should be offered consultation to discuss management decisions with both an endoscopist and surgeon when intervention is considered 2
• Family history should be recorded as there may be genetic factors involved 1

By following these evidence-based guidelines, clinicians can optimize the management of Barrett's esophagus to reduce the risk of progression to esophageal adenocarcinoma while minimizing unnecessary interventions.