Management of Barrett's Esophagus with Distal Esophageal Changes
The management of Barrett's esophagus requires endoscopic surveillance with Seattle protocol biopsies, with surveillance intervals determined by the presence and grade of dysplasia. 1, 2
Diagnosis and Biopsy Protocol
- Endoscopic evaluation should be performed using high-resolution white light endoscopy 1
- Biopsy protocol (Seattle protocol):
- Diagnosis should be confirmed by at least two pathologists, preferably with one expert in esophageal histopathology 2
- Avoid performing biopsies in the presence of active inflammation (erosive esophagitis) 2
Surveillance Intervals
Surveillance intervals are determined by the presence and grade of dysplasia:
- No dysplasia: Every 3-5 years 1, 2
- Indefinite for dysplasia: Every 6 months with dose optimization of acid-suppressant medication 1
- Low-grade dysplasia: Every 6-12 months 1
- Consider radiofrequency ablation if low-grade dysplasia is confirmed by two gastrointestinal pathologists on biopsies taken at two separate endoscopies 1
- High-grade dysplasia without eradication therapy: Every 3 months 1
Management of Dysplasia and Early Cancer
High-Grade Dysplasia
- Offer endoscopic resection of visible lesions as first-line treatment 1
- Offer endoscopic ablation of any residual Barrett's esophagus after endoscopic resection 1
Low-Grade Dysplasia
- Offer radiofrequency ablation if confirmed by two gastrointestinal pathologists on biopsies from two separate endoscopies 1
Stage 1 Esophageal Adenocarcinoma
- T1a (mucosal) cancer: Offer endoscopic resection as first-line treatment, followed by ablation of any residual Barrett's esophagus 1
- T1b (submucosal) cancer: Offer oesophagectomy to patients fit for surgery and at high risk of cancer progression (e.g., incomplete endoscopic resection, lymphovascular invasion, or deep submucosal invasion >500 μm) 1
- Consider radiotherapy (alone or with chemotherapy) for T1b cancer patients unfit for oesophagectomy 1
Medical Therapy
- Proton pump inhibitors (PPIs) are recommended for symptom control of GERD 2, 3
- PPI dose should be optimized for symptom control, not for cancer prevention 2
- Omeprazole and other PPIs effectively reduce acid secretion, with doses of 20-40 mg providing significant reduction in 24-hour intragastric acidity (80-97% decrease) 3
- Anti-reflux surgery is not more effective than medical therapy for cancer prevention 1, 2
- Do not offer aspirin to prevent progression to dysplasia or cancer 1
Lifestyle Modifications
- Weight management
- Elevation of the head of the bed
- Avoiding meals within 3 hours of bedtime
- Limiting alcohol consumption 2
Patient Education and Follow-up
- Provide verbal and written information about Barrett's esophagus diagnosis, treatment options, and available support groups 2
- Record family history as there may be genetic factors involved 2
- Screen for cardiovascular risk factors, as cardiovascular deaths are more common than deaths from esophageal adenocarcinoma in these patients 2
Important Caveats and Pitfalls
Diagnostic challenges: Significant interobserver variability exists among pathologists in diagnosing dysplasia. Confirmation by expert GI pathologists is crucial 2.
Surveillance limitations: Despite being standard practice, endoscopic surveillance has not been definitively proven to reduce mortality from esophageal adenocarcinoma in randomized controlled trials 1, 4.
Overdiagnosis of low-grade dysplasia: Low-grade dysplasia tends to be overcalled by community pathologists, especially during initial examinations when esophageal inflammation may be present 1.
Surveillance adherence: Studies suggest that adherence to recommended surveillance protocols is associated with higher rates of dysplasia and cancer detection, but many practicing gastroenterologists do not adhere to these guidelines 1.
Biomarkers: Current evidence does not support the use of molecular biomarkers to confirm dysplasia diagnosis or for risk stratification 1.