What is the management approach for patients with Barrett's esophagus and low-grade dysplasia?

Management of Barrett's Esophagus with Low-Grade Dysplasia

Endoscopic eradication therapy with radiofrequency ablation (RFA) should be offered to patients with confirmed and persistent low-grade dysplasia (LGD) in Barrett's esophagus, as this significantly reduces progression to high-grade dysplasia or esophageal adenocarcinoma compared to surveillance alone. 1, 2

Initial Diagnostic Confirmation

The diagnosis of LGD must be confirmed by an expert gastrointestinal pathologist before proceeding with any management decisions 1. This is critical because LGD is frequently overcalled by community pathologists, particularly when esophageal inflammation is present 1.

If the diagnosis is downgraded to non-dysplastic Barrett's esophagus upon expert review, manage the patient as non-dysplastic Barrett's esophagus with surveillance every 3-5 years. 1

Repeat Endoscopy Under Optimal Conditions

Once LGD is confirmed by expert pathology review, perform a repeat high-definition/high-resolution white-light endoscopy within 8-12 weeks under maximal acid suppression (twice-daily proton pump inhibitor therapy) 1. This repeat endoscopy serves to:

• Detect any visible lesions that may have been missed initially 1
• Confirm persistence of LGD after optimizing acid suppression 1
• Avoid performing biopsies in the presence of active erosive esophagitis (Los Angeles grade C or D), which can lead to false-positive dysplasia diagnoses 1

Use the Seattle biopsy protocol: obtain 4-quadrant biopsies every 1-2 cm throughout the Barrett's segment, with separate targeted biopsies of any visible abnormalities taken first. 1

Management Decision: Ablation vs. Surveillance

For patients with confirmed and persistent LGD on the repeat endoscopy, two management options exist, and the choice should be discussed with the patient 1:

Option 1: Endoscopic Eradication Therapy (Preferred)

Radiofrequency ablation is the recommended ablative modality for LGD. 1 The 2024 NICE guidelines specifically recommend offering RFA to patients with LGD diagnosed from biopsy samples taken at two separate endoscopies, with confirmation by two gastrointestinal pathologists 1. This recommendation is supported by meta-analysis data showing RFA significantly reduces progression to HGD or esophageal adenocarcinoma (OR: 0.17,95% CI: 0.04-0.65) 2.

Any visible lesions must undergo endoscopic resection first to accurately assess the true grade of dysplasia before proceeding with ablation. 1 This is crucial because visible abnormalities may harbor higher-grade dysplasia or early cancer.

The goal of endoscopic eradication therapy is complete eradication of intestinal metaplasia 1.

Option 2: Endoscopic Surveillance

If the patient declines ablation or is not a candidate for endoscopic therapy, surveillance is an acceptable alternative 1, 3. However, surveillance carries a higher risk of progression compared to ablation 2.

Surveillance intervals for LGD without ablation:

• Every 6 months for the first year (some guidelines recommend 2 years) 1
• Then annually thereafter 1
• Continue using the Seattle biopsy protocol (4-quadrant biopsies every 1-2 cm) 1

The 2011 AGA guidelines suggested 6-12 month intervals 1, while the 2014 British Society of Gastroenterology recommended 6-monthly surveillance 1.

Post-Ablation Surveillance

After achieving complete eradication of intestinal metaplasia with RFA:

• Perform surveillance endoscopy annually for 2 years 1
• Then every 3 years thereafter 1
• Obtain 4-quadrant biopsies every 2 cm throughout the original Barrett's segment length 1

If complete eradication of intestinal metaplasia is not achieved, surveillance should be more frequent: every 6 months for 1 year, then annually for 2 years, then every 3 years 1.

Critical Referral Requirements

All patients with confirmed LGD should be referred to an endoscopist with expertise in managing Barrett's esophagus-related neoplasia, practicing at centers equipped with high-definition endoscopy and capable of performing endoscopic resection and ablation. 1 This referral is essential for optimal outcomes, as expertise significantly impacts detection rates and treatment success.

Common Pitfalls to Avoid

• Do not proceed with management decisions based on community pathology alone - always obtain expert GI pathology confirmation 1
• Do not perform surveillance biopsies in the presence of severe erosive esophagitis - optimize acid suppression first and repeat after inflammation resolves 1
• Do not ablate visible lesions - these require endoscopic resection first for accurate histologic staging 1
• Do not offer aspirin for chemoprevention - this is not recommended 1