What is the management plan for Barrett's esophagus?

Management of Barrett's Esophagus

The management of Barrett's esophagus should be stratified based on the presence and degree of dysplasia, with endoscopic eradication therapy strongly recommended for high-grade dysplasia to prevent progression to esophageal adenocarcinoma. 1, 2

Diagnosis and Surveillance

• Barrett's esophagus is defined as the presence of intestinal metaplasia in any length of the tubular esophagus, representing a change from normal squamous epithelium to columnar epithelium due to chronic gastroesophageal reflux disease 3
• The diagnosis of dysplasia should be confirmed by at least two pathologists, preferably with one being an expert in esophageal histopathology, before initiating any endoscopic eradication therapy 4
• For non-dysplastic Barrett's esophagus, surveillance intervals should be every 3-5 years 1, 5
• For patients with Barrett's esophagus without dysplasia, proper biopsy protocol includes 4-quadrant biopsies every 2 cm of Barrett's segment 4, 2
• For patients with known or suspected dysplasia, 4-quadrant biopsies should be taken every 1 cm 4, 2
• Long-segment Barrett's esophagus (≥3 cm) carries a higher risk of progression to dysplasia and cancer compared to short-segment Barrett's (<3 cm), potentially warranting more frequent surveillance 6

Medical Management

• 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 1, 2
• There is insufficient evidence to recommend high-dose PPI therapy solely to prevent progression to dysplasia or cancer 1
• Antireflux surgery is not more effective than medical GERD therapy for the prevention of cancer in Barrett's esophagus 4, 1
• Antireflux surgery should only be considered in patients with poor or partial symptomatic response to PPIs 1

Management Based on Dysplasia Status

Non-dysplastic Barrett's Esophagus

• Endoscopic eradication therapy is not recommended for patients with non-dysplastic Barrett's esophagus except in select high-risk individuals 3
• Surveillance endoscopy every 3-5 years is the standard of care 1, 7

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
• RFA therapy for patients with low-grade dysplasia leads to reversion to normal-appearing squamous epithelium in 90% of cases 4

High-grade Dysplasia

• Endoscopic eradication therapy with RFA, photodynamic therapy (PDT), or endoscopic mucosal resection (EMR) is strongly recommended rather than surveillance for treatment of patients with confirmed high-grade dysplasia 4, 2
• RFA therapy for patients with high-grade dysplasia reduces progression to esophageal cancer, as shown in randomized controlled trials 4
• 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 4, 2

Endoscopic Eradication Techniques

• The goal of endoscopic eradication therapy is the elimination of all Barrett's epithelium to prevent neoplastic progression 4
• Complete eradication appears to be more effective than therapy that removes only a localized area of dysplasia in Barrett's epithelium 4
• RFA appears to have at least comparable efficacy and fewer serious adverse effects compared with PDT 4
• RFA can lead to reversion of the metaplastic mucosa to normal-appearing squamous epithelium in a high proportion of subjects at any stage of Barrett's esophagus 4

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 4, 1

Common Pitfalls and Caveats

• Avoid attempting to eliminate esophageal acid exposure through high-dose PPIs or antireflux surgery solely for the prevention of esophageal adenocarcinoma 4, 1
• The current literature is inadequate to recommend endoscopic eradication therapy with cryotherapy for patients with confirmed low-grade or high-grade dysplasia 4
• Dysplasia and early cancer often develop without clinical signs, even in patients whose symptoms are well-controlled on acid suppressant medications 3
• Most patients who develop cancer in the setting of Barrett's esophagus were unaware of having the condition before their cancer diagnosis 3

Patient Education and Follow-up

• When Barrett's esophagus is detected, patients should receive an early outpatient appointment to discuss the implications of this diagnosis, including the cancer risk, possible lifestyle changes, and surveillance recommendations 2
• The American Gastroenterological Association strongly supports shared decision making where the treating physician and patient together consider whether endoscopic surveillance or eradication therapy is the preferred management option 4