What is the recommended endoscopic surveillance protocol for patients with Barrett's esophagus according to American Society for Gastrointestinal Endoscopy (ASGE) guidelines?

Barrett's Esophagus Endoscopic Surveillance Protocol

For Barrett's esophagus surveillance, perform endoscopy using white light endoscopy with 4-quadrant biopsies every 2 cm for non-dysplastic Barrett's, and every 1 cm for patients with known or suspected dysplasia, with surveillance intervals of 3-5 years for no dysplasia, 6-12 months for low-grade dysplasia, and every 3 months for high-grade dysplasia without ablation therapy. 1

Surveillance Intervals Based on Dysplasia Grade

The surveillance frequency should be stratified by the presence and grade of dysplasia:

• No dysplasia: Endoscopy every 3-5 years 1, 2
• Low-grade dysplasia: Endoscopy every 6-12 months after confirmation by expert pathologist 1, 2
• High-grade dysplasia (without eradication therapy): Endoscopy every 3 months 1, 2

Important caveat: For short-segment Barrett's (<3 cm), surveillance every 3-5 years is appropriate, while long-segment Barrett's (≥3 cm) may warrant more frequent surveillance every 2-3 years according to some guidelines. 2

Biopsy Protocol During Surveillance

The American Gastroenterological Association provides strong recommendations for the biopsy technique:

Standard Protocol (No Known Dysplasia)

• Use white light endoscopy for inspection 1
• Obtain 4-quadrant biopsies every 2 cm throughout the Barrett's segment 1
• Take targeted biopsies of any mucosal irregularities and submit separately to pathology 1

Enhanced Protocol (Known or Suspected Dysplasia)

• Obtain 4-quadrant biopsies every 1 cm when dysplasia is known or suspected 1
• This more intensive sampling increases dysplasia detection rates 1

Documentation Requirements

• Document Barrett's extent using Prague classification 2
• Minimum 1-minute inspection time per cm of Barrett's length 3
• Photodocumentation of landmarks and one picture per cm of Barrett's length 3

Advanced Imaging Techniques

Chromoendoscopy and advanced imaging techniques (confocal laser endomicroscopy, electronic chromoendoscopy) are NOT recommended for routine surveillance but may be helpful for guiding biopsies in patients with known dysplasia or visible mucosal irregularities. 1

Critical Pitfalls to Avoid

Inadequate Biopsy Sampling

Adherence to the Seattle protocol (4-quadrant biopsies every 2 cm) is associated with higher rates of dysplasia and cancer detection. 1, 2 Many gastroenterologists fail to follow these protocols, particularly in patients with extensive Barrett's metaplasia who are at highest risk. 1

Dysplasia Confirmation

All cases of dysplasia must be confirmed by a second experienced GI pathologist due to significant interobserver variability, particularly for low-grade dysplasia which is frequently overcalled by community pathologists. 1, 2

Inadequate Procedure Time

Longer procedural time is associated with increased dysplasia detection, particularly for Barrett's segments >6 cm. 4 Adequate time slots must be allocated for quality surveillance.

Special Populations

Segment Length Considerations

• Barrett's <1 cm (irregular Z-line): No routine biopsies or surveillance advised 3
• Barrett's ≥10 cm: Refer to Barrett's expert center for surveillance 3

Age and Life Expectancy

Consider discontinuing surveillance if patient reaches 75 years of age or life expectancy is less than 5 years. 3

Post-Eradication Therapy Surveillance

After successful endoscopic eradication therapy, surveillance intervals differ:

• For high-grade dysplasia/cancer baseline: Follow-up at 3,6,12 months, then annually 2
• For low-grade dysplasia baseline: Follow-up at 1 and 3 years 2

Adjunctive Medical Therapy

All patients should be on at least daily proton pump inhibitor therapy during surveillance. 2 However, neither high-dose PPIs nor antireflux surgery are more effective than standard medical GERD therapy for cancer prevention in Barrett's esophagus. 1, 5