What is the first line of management for patients with Barrett esophagus?

First-Line Management of Barrett's Esophagus

The first-line management for patients with Barrett's esophagus consists of proton pump inhibitor (PPI) therapy for symptom control of gastroesophageal reflux disease (GERD) combined with endoscopic surveillance using high-resolution white light endoscopy with Seattle biopsy protocol. 1, 2

Medical Management for Symptom Control

• PPIs are the cornerstone of medical therapy for Barrett's esophagus and should be used primarily for GERD symptom control, not for cancer prevention 1, 2
• Standard once-daily PPI dosing is appropriate—do not attempt to eliminate esophageal acid exposure through high-dose PPIs (greater than once daily) or pH monitoring to titrate dosing, as this does not prevent progression to esophageal adenocarcinoma 1, 3
• Antireflux surgery is not superior to medical therapy for preventing neoplastic progression and should not be offered for cancer prevention purposes 1, 2, 4
• Antireflux surgery should only be considered in patients with poor or partial symptomatic response to PPIs, not as a cancer prevention strategy 2

Endoscopic Surveillance Protocol

All patients with Barrett's esophagus require endoscopic surveillance to monitor for progression to dysplasia and adenocarcinoma 2, 3

Surveillance Technique

• Use high-resolution white light endoscopy with Seattle biopsy protocol as the standard approach 1, 4
• Take 4-quadrant biopsies every 2 cm throughout the Barrett's segment for patients without known dysplasia 1, 2, 3
• Take 4-quadrant biopsies every 1 cm for patients with known or suspected dysplasia 1, 2
• Obtain specific biopsy specimens of any mucosal irregularities and submit them separately to the pathologist 1
• Chromoendoscopy or advanced imaging techniques are not required for routine surveillance 1

Surveillance Intervals Based on Dysplasia Status

For non-dysplastic Barrett's esophagus:

• Perform surveillance endoscopy every 3-5 years 1, 2, 4
• Ensure the benefits of surveillance outweigh risks based on the patient's overall health status 1, 4

For indefinite dysplasia:

• Consider endoscopic surveillance at 6-month intervals with dose optimization of acid-suppressant medication 1, 4

For low-grade dysplasia:

• Confirm diagnosis with biopsy samples from two separate endoscopies, verified by two gastrointestinal pathologists 1, 4
• Offer radiofrequency ablation once confirmed 1, 4

For high-grade dysplasia:

• Offer endoscopic resection of visible lesions as first-line treatment 1, 4
• Follow with endoscopic ablation of any residual Barrett's esophagus after endoscopic resection 1, 4

Chemoprevention: What NOT to Do

• Do not offer aspirin to patients with Barrett's esophagus specifically to prevent progression to dysplasia or cancer 1, 4
• However, screen patients for cardiovascular risk factors for which aspirin therapy might be indicated for other reasons 1, 2
• There is insufficient evidence to support NSAIDs or other chemopreventive agents specifically for Barrett's esophagus 2

Patient Education and Follow-Up

• Offer a clinical consultation immediately after diagnosis to discuss the annual rate of progression to adenocarcinoma of approximately 0.2-0.5% 4
• Provide both verbal and written information about the diagnosis, treatment options, and patient support groups 1, 4
• After each surveillance procedure, provide an endoscopy report that includes a lay summary of findings and reference to ongoing symptom control 1

Critical Pitfalls to Avoid

• Do not use high-dose PPIs or antireflux surgery for cancer prevention—the evidence does not support this approach 1, 3, 4
• Ensure all dysplasia diagnoses are confirmed by at least two expert gastrointestinal pathologists before initiating treatment to avoid unnecessary interventions 4
• Do not use CT before endoscopic resection for staging suspected T1 adenocarcinoma 1, 4
• Do not use endoscopic ultrasonography before endoscopic resection for staging suspected T1a adenocarcinoma 1, 4