What is the management of Barrett’s esophagus with low-grade dysplasia?

Management of Barrett's Esophagus with Low-Grade Dysplasia

For patients with Barrett's esophagus and low-grade dysplasia, offer radiofrequency ablation after confirming the diagnosis with biopsy samples from two separate endoscopies verified by two expert gastrointestinal pathologists. 1, 2

Diagnostic Confirmation Requirements

The diagnosis of low-grade dysplasia is notoriously unreliable and requires rigorous confirmation before proceeding with treatment:

• Mandate confirmation by at least two expert gastrointestinal pathologists before any therapeutic intervention, as low-grade dysplasia is frequently overcalled by community pathologists, particularly when esophageal inflammation is present 1, 2

• Obtain biopsy samples from two separate endoscopic examinations to confirm the diagnosis, as this reduces false-positive diagnoses and prevents unnecessary interventions 1, 2

• Refer all patients with confirmed low-grade dysplasia to an expert Barrett's center for re-staging endoscopy, as 23% of patients with apparent flat Barrett's esophagus and confirmed low-grade dysplasia actually have prevalent high-grade dysplasia or cancer when re-examined by expert endoscopists 3

Treatment Strategy

Once low-grade dysplasia is confirmed through the above rigorous pathway:

• Offer radiofrequency ablation as the primary treatment, as this reduces the 3-year risk of progression to high-grade dysplasia or adenocarcinoma by 25% (1.5% with ablation vs 26.5% with surveillance alone, P < 0.001) 4

• Radiofrequency ablation also reduces progression to adenocarcinoma by 7.4% (1.5% with ablation vs 8.8% with surveillance, P = 0.03), demonstrating clear mortality benefit 4

• Achieve complete eradication of dysplasia in 92.6% and intestinal metaplasia in 88.2% of patients treated with radiofrequency ablation, compared to only 27.9% and 0% respectively with surveillance alone 4

High-Risk Features Requiring Aggressive Approach

Certain patients with low-grade dysplasia warrant particularly close attention or immediate endoscopic resection:

• Patients with nodularity at index endoscopy have significantly higher progression risk and should be considered for endoscopic mucosal resection of visible lesions rather than ablation alone 5

• Multifocal low-grade dysplasia (dysplasia at multiple locations) is a significant risk factor for progression to high-grade dysplasia or cancer 5

• Patients with diffuse endoscopically visible low-grade dysplasia should undergo extensive endoscopic mucosal resection of the visibly abnormal area, as 77% of resection specimens contain low-grade dysplasia, 17% contain high-grade dysplasia, and 2% contain early adenocarcinoma 6

Surveillance Protocol for Confirmed Low-Grade Dysplasia

If radiofrequency ablation is declined or deferred:

• Perform endoscopic surveillance at 6-12 month intervals using high-resolution white light endoscopy with Seattle protocol biopsies (four-quadrant biopsies every 2 cm throughout the Barrett's segment) 1, 2

• Optimize acid-suppressant medication dosing during surveillance to minimize inflammation that can confound dysplasia diagnosis 1, 2

Management After Radiofrequency Ablation

• Offer endoscopic follow-up to all patients who receive endoscopic treatment for Barrett's esophagus with dysplasia to monitor for recurrence 1

• Continue proton pump inhibitor therapy for symptom control, though this should not be prescribed specifically for cancer prevention 2, 7

Critical Pitfalls to Avoid

• Do not proceed with ablation based on a single pathologist's diagnosis or single endoscopy, as the false-positive rate for low-grade dysplasia is extremely high in community practice 1, 3

• Do not offer anti-reflux surgery to prevent progression to dysplasia or cancer, as evidence does not support this intervention for cancer prevention 1, 2

• Do not offer aspirin specifically to prevent progression, as guidelines explicitly recommend against this practice 2, 7

• Do not perform surveillance at 3-5 year intervals as recommended for non-dysplastic Barrett's esophagus, since confirmed low-grade dysplasia carries substantially higher progression risk with 41% progressing at 5 years 5

Treatment-Related Adverse Events

• Expect treatment-related adverse events in approximately 19% of patients receiving radiofrequency ablation, with stricture formation being the most common complication occurring in 11.8% of patients 4

• All strictures resolve with endoscopic dilation, typically requiring only one dilation session (median) 4