What is the diagnostic and treatment approach for a patient with suspected Barrett's esophagitis?

Barrett's Esophagus: Diagnostic and Treatment Approach

Barrett's esophagus requires endoscopic confirmation with histologic documentation of intestinal metaplasia using the Seattle biopsy protocol, followed by risk-stratified surveillance or endoscopic eradication therapy based on dysplasia grade. 1

Screening and Case Identification

Screen patients with ≥3 established risk factors: male sex, non-Hispanic white race, age >50 years, smoking history, chronic GERD, obesity, or family history of Barrett's esophagus or esophageal adenocarcinoma. 1

• Nonendoscopic cell-collection devices may be considered as an alternative screening option for appropriate patients. 1
• Standard upper endoscopy remains the primary screening modality when indicated. 1

Diagnostic Endoscopy Requirements

Use high-definition white light endoscopy with virtual chromoendoscopy for all screening and surveillance examinations. 1

Critical Endoscopic Documentation

• Document Barrett's extent using Prague classification: Record both the circumferential (C) and maximal (M) extent of columnar-lined esophagus with clear landmark descriptions. 1
• Describe any visible lesions including nodularity, ulceration, or irregularities using Paris classification. 1
• Advanced imaging technologies (endomicroscopy) may be used adjunctively to identify dysplasia. 1

Biopsy Protocol (Seattle Protocol)

Obtain four-quadrant biopsies every 1-2 cm throughout the Barrett's segment, plus targeted biopsies of any visible lesions taken first. 1, 2

• Take targeted biopsies of visible lesions before random biopsies to avoid obscured views from bleeding. 2
• Wide-area transepithelial sampling may be used as an adjunctive technique in addition to (not replacing) the Seattle protocol. 1

Special Circumstance: Erosive Esophagitis

If erosive esophagitis is present, optimize acid suppression first before making diagnostic decisions. 1

• Biopsies may be obtained when dysplasia or malignancy is suspected, but repeat endoscopy is mandatory. 1
• Prescribe twice-daily proton pump inhibitor therapy for 8 weeks, then repeat endoscopy to assess for Barrett's after inflammation resolves. 1, 3
• Approximately 12% of patients with healed erosive esophagitis will have underlying Barrett's esophagus detected on repeat examination. 3

Histologic Confirmation

Intestinal metaplasia documented on histology is the prerequisite criterion for Barrett's esophagus diagnosis. 1

• Special stains (Alcian blue, PAS) are not routinely required but may help confirm intestinal metaplasia in select cases with rare goblet cells or prominent pseudogoblet cells. 1
• All dysplasia diagnoses must be confirmed by expert gastrointestinal pathology review due to significant interobserver variability among pathologists. 1, 4

Management Based on Dysplasia Grade

Non-Dysplastic Barrett's Esophagus

• Prescribe at least daily proton pump inhibitor therapy for all patients with Barrett's esophagus. 1, 5
• Surveillance endoscopy every 3-5 years using the Seattle biopsy protocol. 1
• Tissue-based prediction assays may be utilized for risk stratification. 1

Low-Grade Dysplasia (LGD)

Confirm diagnosis with expert GI pathology review before proceeding with management decisions. 1, 4

• Repeat endoscopy in 8-12 weeks under maximal acid suppression (twice-daily PPI) after initial LGD diagnosis. 1
• If LGD is confirmed and persists on repeat endoscopy: Refer to expert endoscopist and discuss endoscopic eradication therapy versus surveillance. 1, 4
• Endoscopic resection is mandatory for any visible lesions to accurately assess true dysplasia grade before ablation. 1, 4
• Radiofrequency ablation should be used if endoscopic eradication therapy is chosen, with goal of complete eradication of intestinal metaplasia. 1, 4
• If surveillance chosen instead of ablation: Every 6 months for first year, then annually thereafter. 1, 4

High-Grade Dysplasia or Neoplasia

Refer all patients to endoscopists with expertise in advanced imaging, resection, and ablation at specialized centers. 1

• Expert high-resolution endoscopy is mandatory to detect visible abnormalities suitable for endoscopic resection. 1
• Visible lesions should be considered malignant until proven otherwise. 1
• Management decisions should be made in context of upper GI specialist multidisciplinary team. 1

Post-Eradication Surveillance

After achieving complete eradication of intestinal metaplasia: 1, 4

• Surveillance endoscopy annually for 2 years, then every 3 years thereafter. 1, 4
• Obtain biopsies from esophagogastric junction, gastric cardia, distal 2 cm of neosquamous epithelium, and all visible lesions regardless of original Barrett's length. 1, 2

Critical Pitfalls to Avoid

• Never proceed with management based on community pathology alone - always obtain expert GI pathology confirmation for any dysplasia. 1, 4
• Never perform surveillance biopsies during active severe erosive esophagitis - optimize acid suppression first. 1, 4
• Never ablate visible lesions - these require endoscopic resection first for accurate histologic staging. 1, 4
• Never rely on endoscopic appearance alone - histologic confirmation with intestinal metaplasia is mandatory for diagnosis. 1