What is the management approach for Barrett's esophagus?

Management of Barrett's Esophagus

The management of Barrett's esophagus should be stratified based on the presence and grade of dysplasia, with endoscopic eradication therapy strongly recommended for patients with confirmed dysplasia and surveillance for those without dysplasia. 1

Diagnosis and Initial Assessment

• Barrett's esophagus diagnosis requires:

  • Confirmation by at least 2 pathologists, preferably with one expert in esophageal histopathology 2, 1
  • Diagnosis should not be made during active inflammation/erosive esophagitis 1
  • Specific biopsy specimens of any mucosal irregularities should be submitted separately 2

• During endoscopic evaluation:

  • Use high-resolution white-light endoscopy 1, 3
  • Minimum 1-minute inspection time per cm of Barrett's length 3
  • Photodocumentation of landmarks and any visible lesions 3
  • Use of Prague classification for Barrett's extent and Paris classification for visible lesions 3

Surveillance Protocol

Surveillance intervals should be determined by Barrett's segment length:

• For Barrett's <1 cm (irregular Z-line): No routine biopsies or surveillance needed 3
• For Barrett's 1-3 cm: Surveillance every 5 years 3 or 3-5 years 4
• For Barrett's 3-10 cm: Surveillance every 3 years 3
• For Barrett's ≥10 cm: Referral to expert center 3

Biopsy protocol:

• 4-quadrant biopsies every 2 cm in patients without known dysplasia 2
• 4-quadrant biopsies every 1 cm in patients with known or suspected dysplasia 2
• Targeted biopsies of any visible abnormalities 2, 1

Management Based on Dysplasia Status

Non-dysplastic Barrett's Esophagus

• Endoscopic surveillance at intervals based on segment length (as above)
• Proton pump inhibitors (PPIs) for symptom control of GERD 1
• PPI dose should be optimized for symptom control, not for cancer prevention 1
• Endoscopic eradication therapy is not routinely recommended but may be considered for select high-risk individuals 2

Low-Grade Dysplasia (LGD)

• Diagnosis must be confirmed by at least two pathologists 2, 1
• Endoscopic eradication therapy with radiofrequency ablation (RFA) is strongly recommended 2, 1, 3
• RFA leads to reversion to normal-appearing squamous epithelium in 90% of cases 2
• Surveillance remains an acceptable alternative 4

High-Grade Dysplasia (HGD)

• Endoscopic eradication therapy is strongly recommended to prevent progression to cancer 2, 1, 3
• EMR should be performed for any visible lesions to determine T stage 2
• Complete eradication of all Barrett's epithelium should be the goal 2

T1a Esophageal Adenocarcinoma

• Endoscopic mucosal resection (EMR) is recommended as curative treatment for well/moderately differentiated T1a cancer without lymphovascular invasion 3
• Complete eradication of all remaining Barrett's epithelium by ablation after EMR 3

T1b Esophageal Adenocarcinoma

• Low-risk T1b (≤500 µm submucosal invasion, no lymphovascular invasion, no poor differentiation): Consider endoscopic resection with close follow-up 3
• High-risk T1b (>500 µm invasion, lymphovascular invasion, or poor differentiation): Consider additional treatments (chemotherapy, radiotherapy, surgery) 3

Post-Treatment Surveillance

After successful endoscopic eradication therapy:

• For patients with baseline HGD or cancer: Surveillance at 1,2,3,4,5,7, and 10 years 3
• For patients with baseline LGD: Surveillance at 1,3, and 5 years 3
• First follow-up should be performed in an expert center 3
• Careful inspection of neo-squamocolumnar junction with high-definition white-light endoscopy 3
• Targeted biopsies of any suspicious areas 3
• Biopsies just distal to neo-squamocolumnar junction to detect dysplasia 3

Medical Management

• PPIs are recommended for symptom control of GERD 1, 5
• PPI therapy reduces acid exposure but has not been definitively shown to prevent progression to cancer 6
• Omeprazole and other PPIs effectively reduce acid secretion 5, with doses of 20-40mg providing significant reduction in intragastric acidity 5

Surgical Management

• Anti-reflux surgery is not more effective than medical therapy for cancer prevention 2, 1, 6
• Surgery should be considered for GERD symptom control, not for cancer prevention 6

Additional Considerations

• Screening for cardiovascular risk factors is recommended as cardiovascular deaths are more common than deaths from esophageal adenocarcinoma 1
• Consider discontinuing surveillance at age 75 or when life expectancy is less than 5 years 3
• Lifestyle modifications including weight management, elevation of the head of the bed, avoiding meals within 3 hours of bedtime, and limiting alcohol consumption should be recommended 1
• Patient education should include discussions about cancer risk, surveillance plans, and symptom control 1

Pitfalls and Caveats

• Diagnosis of dysplasia has significant interobserver variability; confirmation by expert pathologists is crucial
• Surveillance biopsies should not be performed during active inflammation/erosive esophagitis
• PPIs should not be prescribed at high doses solely for cancer prevention
• Endoscopic eradication therapy should be performed at centers with expertise and high-definition endoscopy
• Recurrence of Barrett's esophagus after ablation is relatively common, necessitating continued surveillance