What is the treatment plan for patients with Barrett's esophagus?

Treatment Plan for Barrett's Esophagus

The treatment plan for Barrett's esophagus should include proton pump inhibitor therapy for symptom control, appropriate endoscopic surveillance based on dysplasia status, and endoscopic eradication therapy for patients with dysplasia. 1, 2

Initial Management

• Clinical consultation: Offer patients with newly diagnosed Barrett's esophagus a dedicated consultation to discuss:

  • Cancer risk
  • Endoscopic surveillance plans
  • Symptom control options 1

• Patient education: Provide verbal and written information about:

  • Diagnosis
  • Available treatments
  • Patient support groups 1

• Symptom control:

  • First-line: Proton pump inhibitors (PPIs) for GERD symptom management
  • PPI dose should be optimized for symptom control, not for cancer prevention 2
  • Example: Omeprazole 20-40 mg daily (produces 80-97% decrease in 24-hour intragastric acidity) 3

Surveillance Protocol

Surveillance intervals depend on the presence and grade of dysplasia:

• No dysplasia:

  • Barrett's <3cm: Every 3-5 years 2
  • Barrett's ≥3cm: Every 2-3 years 2

• Indefinite for dysplasia:

  • Every 6 months with dose optimization of acid-suppressant medication 1

• Low-grade dysplasia:

  • Every 6-12 months 2

• High-grade dysplasia (without eradication therapy):

  • Every 3 months 2

Surveillance Technique

• Use high-resolution white-light endoscopy with Seattle protocol biopsies:
  • 4-quadrant biopsies every 2 cm in patients without known dysplasia
  • 4-quadrant biopsies every 1 cm in patients with known or suspected dysplasia
  • Targeted biopsies of any visible abnormalities 2
  • Minimum 1-minute inspection time per cm of Barrett's length 2

Management of Dysplasia and Early Cancer

• Low-grade dysplasia:

  • Offer radiofrequency ablation if confirmed by two gastrointestinal pathologists on biopsies taken at two separate endoscopies 1, 2

• High-grade dysplasia:

  • Offer endoscopic resection of visible lesions as first-line treatment
  • Follow with endoscopic ablation of any residual Barrett's esophagus 1, 2

• T1a (mucosal) cancer:

  • Offer endoscopic resection as first-line treatment
  • Follow with endoscopic ablation of any residual Barrett's esophagus 1, 2

• 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, 2

Post-Treatment Follow-up

• Offer endoscopic follow-up to patients who have received endoscopic treatment for:
  • Barrett's esophagus with dysplasia
  • Stage 1 oesophageal adenocarcinoma 1

Lifestyle Modifications

• Recommend weight management
• Elevate the head of the bed
• Avoid meals within 3 hours of bedtime
• Limit alcohol consumption 2

Important Considerations and Pitfalls

• Do not offer aspirin specifically to prevent progression to oesophageal dysplasia and cancer 1
• Diagnostic confirmation: Diagnosis of dysplasia requires confirmation by at least two pathologists, preferably with one expert in esophageal histopathology 2
• Surveillance limitations: Despite being standard practice, endoscopic surveillance has not been definitively proven to reduce mortality from esophageal adenocarcinoma in randomized controlled trials 2
• Interobserver variability: Significant variability exists among pathologists in diagnosing dysplasia, making expert confirmation crucial 2
• Biomarkers: Current evidence does not support the use of molecular biomarkers to confirm dysplasia diagnosis or for risk stratification 2

Cardiovascular Risk Assessment

• Screen for cardiovascular risk factors as cardiovascular deaths are more common than deaths from esophageal adenocarcinoma in these patients 2