What is the first line of management for patients with Barrett's esophagus?

Management of Barrett's Esophagus

The first line of management for patients with Barrett's esophagus is proton pump inhibitor (PPI) therapy for symptom control, along with endoscopic surveillance based on the presence or absence of dysplasia. 1

Medical Management

• Proton Pump Inhibitors (PPIs):

  • Standard PPI dosing is recommended as first-line therapy for symptom management 1
  • Higher doses of PPIs beyond once daily are not recommended solely for cancer prevention 1
  • PPIs help control reflux symptoms but have not been definitively proven to prevent neoplastic progression 2

• Lifestyle Modifications:

  • Weight management
  • Elevation of the head of the bed
  • Avoiding meals within 3 hours of bedtime
  • Limiting alcohol consumption 1

Surveillance Strategy

Surveillance frequency depends on the presence of dysplasia:

Non-dysplastic Barrett's Esophagus:

• For Barrett's <3cm with intestinal metaplasia: surveillance every 3-5 years 1
• For Barrett's ≥3cm: surveillance every 2-3 years 1

Low-Grade Dysplasia (LGD):

• Confirm diagnosis with expert GI pathologist review 2
• Repeat endoscopy using high-definition white-light endoscopy under maximal acid suppression (twice daily PPI) in 8-12 weeks 2
• If LGD persists, consider radiofrequency ablation 2
• If opting for surveillance instead of ablation: endoscopy every 6 months for 1 year, then annually 2

High-Grade Dysplasia (HGD):

• Offer endoscopic resection of visible lesions as first-line treatment 2
• Follow with endoscopic ablation of any residual Barrett's esophagus 2

Endoscopic Techniques

• Endoscopic Surveillance:

  • High-resolution white-light endoscopy with Seattle protocol biopsy (four quadrants every 1-2 cm) 1
  • Target biopsies of any visible lesions 2

• Endoscopic Eradication Therapy:

  • For visible lesions: Endoscopic resection to determine T stage 1
  • For T1a (mucosal) lesions: Endoscopic resection followed by ablation of residual Barrett's 2
  • For T1b (submucosal) lesions in patients fit for surgery: Esophagectomy 2
  • For T1b lesions in patients unfit for surgery: Consider radiotherapy (alone or with chemotherapy) 2

Important Considerations and Pitfalls

1. Diagnostic Confirmation:

   • Diagnosis of LGD should be confirmed by an expert GI pathologist due to significant interobserver variability 2
   • Surveillance biopsies should not be performed in the presence of active inflammation (erosive esophagitis) 2

2. Referral Criteria:

   • Patients with confirmed LGD should be referred to centers with expertise in managing Barrett's-related neoplasia 2
   • Endoscopic eradication therapy should be performed at centers equipped with high-definition endoscopy 2

3. Common Pitfalls:

   • Relying on a single pathologist's diagnosis of dysplasia
   • Performing biopsies during active inflammation, which can mimic dysplasia
   • Failing to document Barrett's extent using standardized classification (Prague)
   • Inadequate biopsy sampling (four quadrants every 1-2 cm is standard)

4. Anti-reflux Surgery:

   • Anti-reflux surgery is not recommended to prevent progression to dysplasia or cancer 2
   • Surgery should be considered only in patients with poor or partial symptomatic response to PPIs 2
   • No significant difference in cancer incidence between medically and surgically treated patients 3

Follow-up After Treatment

• After endoscopic eradication therapy, patients should undergo surveillance every year for 2 years and then every 3 years 1
• Biopsy protocol should include 4 quadrants every 2 cm throughout the length of the esophagus 2
• Patients who have received endoscopic treatment for Barrett's esophagus with dysplasia or stage 1 esophageal adenocarcinoma should be offered endoscopic follow-up 2

By following this structured approach to Barrett's esophagus management, clinicians can effectively control symptoms, monitor for progression, and intervene appropriately when dysplasia or early cancer develops.