What is the treatment for Barrett's esophagus?

Treatment of Barrett's Esophagus

The treatment of Barrett's esophagus should be stratified based on the presence and grade of dysplasia, with medical management using proton pump inhibitors for symptom control in non-dysplastic Barrett's, and endoscopic eradication therapy recommended for dysplastic Barrett's esophagus. 1

Medical Management for Non-Dysplastic Barrett's Esophagus

• Proton pump inhibitors (PPIs) are the cornerstone of medical therapy for Barrett's esophagus and should be used for symptom control of gastroesophageal reflux disease (GERD) 2, 3
• Standard PPI therapy (such as omeprazole 20-40mg daily) effectively controls reflux symptoms by reducing gastric acid production 4, 5
• There is insufficient evidence to recommend high-dose PPI therapy solely to prevent progression to dysplasia or cancer 1
• Antireflux surgery is not superior to medical therapy for preventing neoplastic progression of Barrett's esophagus and should not be offered for this purpose 1
• Antireflux surgery should only be considered in patients with poor or partial symptomatic response to PPIs 1, 3

Surveillance Recommendations

• All patients with Barrett's esophagus should undergo endoscopic surveillance to monitor for progression to dysplasia and adenocarcinoma 2, 5
• For non-dysplastic Barrett's esophagus, surveillance intervals should be every 3-5 years 2, 6
• 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 dysplasia 1, 2
• For patients diagnosed with indefinite dysplasia, consider endoscopic surveillance at 6-month intervals with optimization of acid-suppressant medication 1, 7

Management of Dysplastic Barrett's Esophagus

Low-Grade Dysplasia

• Radiofrequency ablation (RFA) should be offered to patients with confirmed low-grade dysplasia diagnosed from biopsy samples taken at two separate endoscopies 1
• The diagnosis should be confirmed by two gastrointestinal pathologists 1, 7

High-Grade Dysplasia

• Endoscopic resection of visible lesions should be offered as first-line treatment for high-grade dysplasia 1
• Endoscopic ablation of any residual Barrett's esophagus should be offered after endoscopic resection 1
• Endoscopic eradication therapy with RFA, photodynamic therapy (PDT), or endoscopic mucosal resection (EMR) is strongly recommended over surveillance for patients with confirmed high-grade dysplasia 1

Management of Early Esophageal Adenocarcinoma (T1)

• Endoscopic resection should be offered as first-line treatment for T1a (intramucosal) esophageal adenocarcinoma 1, 7
• Endoscopic ablation of any residual Barrett's esophagus should be performed after endoscopic resection for T1a adenocarcinoma 1
• For T1b (submucosal) esophageal adenocarcinoma, esophagectomy should be offered to patients who are fit for surgery and at high risk of cancer progression 1
• For patients with T1b adenocarcinoma who are unfit for surgery, radiotherapy (alone or with chemotherapy) should be considered 1

Chemoprevention

• There is insufficient evidence to support the use of aspirin, NSAIDs, or other chemopreventive agents specifically for Barrett's esophagus 1
• Patients should be screened for cardiovascular risk factors for which aspirin therapy might be indicated for other reasons 1
• Aspirin should not be used solely to prevent esophageal adenocarcinoma in the absence of other indications 1

Patient Education and Follow-up

• All patients should be offered an appointment to discuss management decisions 1, 2
• When intervention is considered, therapeutic options should be discussed with both an endoscopist and a surgeon 1, 6
• Endoscopic follow-up should be offered to all patients who have received endoscopic treatment for Barrett's esophagus with dysplasia or early cancer 1, 7

Common Pitfalls and Caveats

• Do not attempt to eliminate esophageal acid exposure through high-dose PPIs or antireflux surgery solely for the prevention of esophageal adenocarcinoma 1, 2
• Do not use endoscopic ultrasonography (EUS) before endoscopic resection for staging suspected T1a esophageal adenocarcinoma 1
• The risk of progression from non-dysplastic Barrett's esophagus to cancer is low (0.2-0.5% annually), so aggressive interventions are not warranted in this population 5, 6
• Ensure that the diagnosis of dysplasia is confirmed by expert gastrointestinal pathologists before initiating treatment 1, 7