Management of Barrett's Esophagus
Barrett's esophagus is an indication for life-long endoscopic surveillance due to its significant risk for progression to esophageal adenocarcinoma. 1
Definition and Risk Factors
- Barrett's esophagus is characterized by the replacement of normal esophageal squamous epithelium with columnar metaplasia in the distal esophagus 2
- It is an acquired condition that in most patients results from chronic gastroesophageal reflux, not congenital in origin 3
- Barrett's esophagus is associated with esophageal adenocarcinoma, not epidermoid (squamous cell) carcinoma of the esophagus 2
- Risk factors include older age, male sex, smoking, central obesity, and Caucasian race 4, 2
Surveillance Recommendations
- Endoscopic surveillance is recommended for all patients with Barrett's esophagus to monitor for progression to dysplasia and adenocarcinoma 1, 5
- For patients with short segment Barrett's (<3 cm) with intestinal metaplasia, surveillance endoscopy should be performed every 3-5 years 5
- For patients with long segment Barrett's (≥3 cm), surveillance endoscopy should be performed every 2-3 years 1, 5
- Proper biopsy protocol includes 4-quadrant biopsies every 2 cm of Barrett's segment for patients without known dysplasia, and every 1 cm for patients with known or suspected dysplasia 1, 5
Medical Management
- Medical therapy with proton pump inhibitors (PPIs) is the cornerstone of treatment for patients with Barrett's esophagus 6
- The American Gastroenterological Association recommends against attempts to eliminate esophageal acid exposure through high-dose PPIs or antireflux surgery for the prevention of esophageal adenocarcinoma 1
- Antireflux surgery is not more effective than medical GERD therapy for the prevention of cancer in Barrett's esophagus 1, 6
- Successful antireflux surgery does not reverse Barrett's esophagus 1
Management of Dysplasia
- For patients with confirmed high-grade dysplasia, endoscopic eradication therapy with radiofrequency ablation (RFA), photodynamic therapy (PDT), or endoscopic mucosal resection (EMR) is recommended rather than surveillance 1
- EMR is recommended for patients who have dysplasia in Barrett's esophagus associated with a visible mucosal irregularity to determine the T stage of the neoplasia 1
- For patients with confirmed low-grade dysplasia, endoscopic eradication therapy with RFA should be considered as a therapeutic option 1
Common Pitfalls to Avoid
- Inadequate biopsy sampling results in significantly lower rates of dysplasia detection; adhere to the Seattle protocol (4-quadrant biopsies every 2 cm) 5
- All cases of suspected dysplasia should be confirmed by a second GI pathologist due to significant interobserver variability 5
- Patients should be on at least daily PPI therapy during surveillance to minimize inflammation that could be misinterpreted as dysplasia 5
Patient Education and Follow-up
- When Barrett's esophagus is detected, patients should receive an early outpatient appointment (ideally within 4-6 weeks) to discuss the implications of this diagnosis 1
- Discussion should include the low but significant cancer risk, possible lifestyle changes, and surveillance recommendations 1
- Written information should be provided for the patient to take away 1
Barrett's esophagus represents a significant risk factor for the development of esophageal adenocarcinoma, with patients having approximately a 0.2% to 0.5% annual rate of developing this cancer 2. The evidence clearly supports lifelong endoscopic surveillance as the standard of care to detect dysplasia or early cancer when intervention is most effective 1.