What are the treatment options for Barrett esophagus?

Treatment Options for Barrett's Esophagus

Treatment for Barrett's esophagus should be tailored based on the presence and grade of dysplasia, with endoscopic eradication therapy being the first-line approach for dysplastic Barrett's esophagus to prevent progression to esophageal adenocarcinoma. 1, 2

Management Based on Dysplasia Status

Non-dysplastic Barrett's Esophagus

• Acid suppression therapy:

  • Proton pump inhibitors (PPIs) are recommended for symptom control 2, 3
  • Standard PPI dosing (e.g., omeprazole 20-40mg daily) is sufficient for symptom management 2, 3
  • Higher PPI doses are not recommended solely for cancer prevention 2
  • PPIs work by inhibiting gastric acid secretion (78-94% decrease in basal acid output) 3

• Surveillance:

  • For Barrett's <3cm with intestinal metaplasia: every 3-5 years 2
  • For Barrett's ≥3cm: every 2-3 years 2, 4
  • For irregular Z-line/columnar-lined esophagus <1cm: no routine surveillance needed 4
  • Consider discontinuing surveillance at age 75 or if life expectancy <5 years 4

Low-Grade Dysplasia (LGD)

• Confirmation: Diagnosis should be confirmed by two expert GI pathologists 2
• Treatment:
  • Radiofrequency ablation (RFA) is recommended for confirmed LGD on at least two separate endoscopies 2, 4
  • Endoscopic surveillance at 6-monthly intervals with optimized acid-suppression if indefinite for dysplasia 1
  • Follow-up after successful eradication: at 1,3, and 5 years 4

High-Grade Dysplasia (HGD)

• Visible lesions: Endoscopic resection as first-line treatment 1, 2
• No visible lesions: Endoscopic ablation to prevent progression to cancer 4
• After resection: Ablation of any residual Barrett's esophagus 1, 2
• Follow-up: At 1,2,3,4,5,7, and 10 years after treatment 4

Early Esophageal Adenocarcinoma

• T1a (mucosal) cancer: Endoscopic resection as first-line treatment 1, 2
• T1b (submucosal) cancer:
  • Low risk (≤500μm invasion, no lymphovascular invasion, well/moderate differentiation): Consider endoscopic resection 4
  • High risk (>500μm invasion, lymphovascular invasion, poor differentiation): Offer esophagectomy if fit for surgery 1
  • For patients unfit for surgery: Consider radiotherapy (alone or with chemotherapy) 1

Endoscopic Surveillance Techniques

• High-resolution white-light endoscopy with Seattle protocol biopsies 1, 2
• Minimum 1-minute inspection time per cm of Barrett's length 4
• Photodocumentation of landmarks and any visible lesions 4
• Four-quadrant biopsies every 2cm throughout Barrett's segment 2, 4
• Target biopsies of any visible abnormalities 2, 4

Post-Treatment Follow-up

• After successful endoscopic eradication therapy:
  • First follow-up should be performed in an expert center 4
  • Careful inspection of neo-squamocolumnar junction with high-definition endoscopy 4
  • Targeted biopsies of any suspicious areas 4
  • Four-quadrant biopsies just distal to neo-squamocolumnar junction 4

Important Caveats and Pitfalls

• Anti-reflux surgery: Not recommended to prevent progression to dysplasia or cancer 1
• Surveillance biopsies: Should not be performed in the presence of active inflammation/erosive esophagitis 2
• Endoscopic procedures: Should be performed at centers with expertise in managing Barrett's-related neoplasia 2
• Cardiovascular risk: Screening for cardiovascular risk factors is warranted as cardiovascular deaths are more common than deaths from esophageal adenocarcinoma 2
• Patient education: Provide verbal and written information about diagnosis, treatment options, and available support groups 2

Barrett's esophagus management requires a systematic approach based on dysplasia status, with the goal of preventing progression to esophageal adenocarcinoma while minimizing unnecessary interventions. The 2024 NICE guidelines provide the most current evidence-based recommendations for this condition 1.