What is the management and treatment for Barrett's esophagus?

Management of Barrett's Esophagus

The management of Barrett's esophagus centers on acid suppression with proton pump inhibitors for symptom control, risk-stratified endoscopic surveillance based on dysplasia grade, and endoscopic therapy (resection followed by ablation) for dysplasia or early cancer—with anti-reflux surgery NOT recommended for cancer prevention. 1, 2

Initial Patient Assessment and Education

• Offer a clinical consultation immediately after diagnosis to discuss the annual cancer progression risk of approximately 0.2-0.5% and establish a surveillance plan 3, 4
• Provide both verbal and written information about the diagnosis, treatment options, and patient support groups to facilitate shared decision-making 2, 3
• Assess overall health status to ensure surveillance benefits outweigh risks, particularly in patients with significant comorbidities 1

Acid Suppression and Symptom Management

• Use proton pump inhibitors (such as omeprazole) as first-line therapy for gastroesophageal reflux symptom control 3, 5
• Optimize acid-suppressant medication dosing, particularly in patients with indefinite dysplasia requiring closer surveillance 1, 2
• Do NOT offer anti-reflux surgery to prevent progression to dysplasia or cancer, as it is not more effective than medical therapy 1, 3
• Do NOT offer aspirin specifically to prevent progression to dysplasia or cancer 3

Endoscopic Surveillance Protocol

• Perform high-resolution white light endoscopy with Seattle protocol biopsies (four-quadrant biopsies every 2 cm throughout the Barrett's segment) for all surveillance examinations 1, 2, 3
• Ensure all dysplasia diagnoses are confirmed by at least two expert gastrointestinal pathologists before proceeding with interventions 2, 3

Risk-Stratified Surveillance Intervals

• Non-dysplastic Barrett's esophagus: Surveillance endoscopy every 3-5 years 3, 6, 4
• Indefinite for dysplasia: Endoscopic surveillance at 6-month intervals with dose optimization of acid-suppressant medication 1, 2, 3
• Low-grade dysplasia: Confirm diagnosis with biopsy samples from two separate endoscopies verified by two gastrointestinal pathologists, then offer radiofrequency ablation 1, 3
• High-grade dysplasia: Proceed directly to endoscopic resection of visible lesions 1, 2

Management of High-Grade Dysplasia

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

The evidence strongly supports endoscopic therapy for high-grade dysplasia, with surveillance patients demonstrating significantly earlier stage tumors and better survival compared to those presenting with prevalent disease 7. Treatment of intramucosal cancer is curative, and improved survival with surveillance is not secondary to lead time bias 7.

Management of Stage 1 Oesophageal Adenocarcinoma

T1a Adenocarcinoma

• Offer endoscopic resection as first-line treatment 1, 2, 3
• Follow with endoscopic ablation of any residual Barrett's esophagus 1, 2, 3
• Provide endoscopic follow-up after treatment 1, 2
• Do NOT use CT before endoscopic resection for staging 1, 3
• Do NOT use endoscopic ultrasonography (EUS) before endoscopic resection for staging 1

T1b Adenocarcinoma

• Offer a clinical consultation to discuss treatment options including endoscopic resection versus oesophagectomy 1, 2
• Consider EUS for nodal staging based on endoscopic appearances or histological examination of endoscopic resection specimens 1, 3
• For patients fit for surgery with high-risk features (incomplete endoscopic resection, lymphovascular invasion, or deep submucosal invasion >500 μm): offer oesophagectomy 1, 3
• For patients unfit for oesophagectomy with high-risk features: consider radiotherapy alone or combined with chemotherapy 1, 3
• Offer endoscopic follow-up after radiotherapy 1

Critical Pitfalls to Avoid

• Never recommend anti-reflux surgery specifically for cancer prevention—evidence does not support this intervention 1, 3
• Never use CT or EUS before endoscopic resection for suspected T1a adenocarcinoma—these add no value and delay definitive treatment 1, 3
• Never proceed with ablation or resection for dysplasia without confirmation by two expert GI pathologists—this prevents unnecessary interventions 2, 3
• Never prescribe aspirin for chemoprevention—this is not supported by evidence 3

Treatment Success Rates

Endoscopic therapy consisting of resection and ablation successfully treats 80% to 90% of patients with Barrett's esophagus and dysplasia or early cancer 4. Radiofrequency ablation significantly reduces progression to cancer in patients with high-grade dysplasia 8. Surveillance programs result in patients being more likely to undergo endoscopic therapy and preserve their esophagus (44% vs 11% in prevalent disease) with better overall and disease-free survival 7.