What is the recommended management and follow-up for a patient with Barrett's esophagus?

Management and Follow-Up of Barrett's Esophagus

Follow patients with Barrett's esophagus using high-resolution white light endoscopy with Seattle biopsy protocol at intervals determined by dysplasia status: every 3-5 years for non-dysplastic Barrett's, combined with proton pump inhibitor therapy for symptom control. 1

Initial Patient Consultation and Education

• Offer a clinical consultation immediately after diagnosis to discuss cancer risk (approximately 0.2-0.5% annual rate of progression to adenocarcinoma), surveillance plans, and symptom management 1, 2
• Provide both verbal and written information about the diagnosis, treatment options, and patient support groups, allowing time for shared decision-making 1
• After each surveillance procedure, provide an endoscopy report with a lay summary of findings and reference to ongoing symptom control 1

Symptom Control and Medical Management

• Manage gastroesophageal reflux symptoms according to NICE guidelines for GERD using proton pump inhibitors as first-line therapy 1, 3
• Do not offer aspirin specifically to prevent progression to dysplasia or cancer 1
• Do not offer anti-reflux surgery to prevent progression to dysplasia or cancer, as it is not more effective than medical therapy 1, 3

Endoscopic Surveillance Protocol

Technique

• Use high-resolution white light endoscopy with Seattle biopsy protocol (four-quadrant biopsies every 2 cm throughout the Barrett's segment) 1
• Ensure the benefits of surveillance outweigh risks based on the patient's overall health status 1

Surveillance Intervals Based on Dysplasia Status

Non-Dysplastic Barrett's Esophagus:

• Perform surveillance endoscopy every 3-5 years 1, 4, 2
• This represents the most common scenario, as the annual cancer risk is only 0.2-0.5% 2

Indefinite for Dysplasia:

• Consider endoscopic surveillance at 6-month intervals with dose optimization of acid-suppressant medication 1, 5

Low-Grade Dysplasia:

• Confirm diagnosis with biopsy samples from two separate endoscopies, verified by two gastrointestinal pathologists 1, 5
• Offer radiofrequency ablation once confirmed by two pathologists 1, 5

High-Grade Dysplasia:

• Offer endoscopic resection of visible lesions as first-line treatment 1, 5
• Offer endoscopic ablation of any residual Barrett's esophagus after endoscopic resection 1, 5

Management of Stage 1 Adenocarcinoma

T1a Adenocarcinoma:

• Offer endoscopic resection as first-line treatment 1, 5
• Follow with endoscopic ablation of residual Barrett's tissue 1, 5
• Provide endoscopic follow-up after treatment 1

T1b Adenocarcinoma:

• For patients fit for surgery with high-risk features (incomplete endoscopic resection, lymphovascular invasion, or deep submucosal invasion >500 μm): offer oesophagectomy 1, 5
• For patients unfit for surgery: consider radiotherapy alone or combined with chemotherapy 1, 5
• Consider endoscopic ultrasound for nodal staging based on endoscopic appearances or histological examination 1, 5

Critical Pathology Confirmation

• Ensure all dysplasia diagnoses are confirmed by at least two expert gastrointestinal pathologists to avoid unnecessary interventions 5
• This is particularly important for low-grade dysplasia, as 75% of initial LGD diagnoses may not be confirmed on subsequent biopsies 6

Common Pitfalls to Avoid

• Over-surveillance is common: Only 15.9% of patients receive appropriate surveillance intervals, with 37.9% being over-surveilled 7
• Do not use CT before endoscopic resection for staging suspected T1 adenocarcinoma 1, 5
• Do not use endoscopic ultrasonography before endoscopic resection for staging suspected T1a adenocarcinoma 1
• Avoid recommending aspirin or anti-reflux surgery specifically for cancer prevention, as evidence does not support these interventions 1, 3