What are the recommended management approaches for patients with Barrett's esophagus, including proton pump inhibitor (PPI) therapy and additional interventions?

Management of Barrett's Esophagus: PPI Therapy and Additional Interventions

Proton Pump Inhibitor Therapy

All patients with Barrett's esophagus should receive long-term PPI therapy indefinitely for symptom control, and PPIs should never be discontinued in these patients. 1, 2

Primary Indication and Dosing

• PPIs are the cornerstone of medical therapy and have the best clinical profile for symptomatic management of GERD in Barrett's esophagus patients. 3, 1

• Standard dosing begins with once-daily PPI therapy for symptom control. 1

• For patients with inadequate clinical response to once-daily therapy, escalate to twice-daily PPI dosing. 2

• Patients with long-segment Barrett's esophagus (>3 cm circumferentially) have particularly high nocturnal acid exposure and may require more aggressive acid suppression. 2

Important Limitation on Chemoprevention

• There is insufficient evidence to recommend high-dose PPI therapy solely to prevent progression to dysplasia or cancer. 3, 1

• While observational data suggest PPIs may reduce dysplasia risk (OR 0.25-0.43 compared to no therapy), no placebo-controlled trial data support using acid suppression drugs as chemopreventive agents. 3

• Despite PPI therapy, many patients continue to have abnormal esophageal acid exposure even without symptoms, particularly nocturnal reflux. 2, 4

Critical Pitfall to Avoid

• Symptom resolution does not guarantee adequate acid reflux control - 22% of patients on omeprazole 20 mg twice daily still had persistent acid reflux on pH monitoring, with nocturnal reflux being most common. 4

Antireflux Surgery

Antireflux surgery is not superior to pharmacological acid suppression for preventing neoplastic progression and should not be offered for this purpose. 3, 1

When to Consider Surgery

• Antireflux surgery should only be considered in patients with poor or partial symptomatic response to PPIs. 3, 1

• When intervention is considered, therapeutic options must be discussed with both an endoscopist and a surgeon. 3, 1

• One RCT comparing surgery versus medical therapy found no difference in progression rates between groups. 3

Endoscopic Surveillance

All patients with Barrett's esophagus require endoscopic surveillance to monitor for progression to dysplasia and adenocarcinoma, regardless of PPI therapy. 1, 2

Surveillance Intervals by Risk Stratification

• Non-dysplastic Barrett's esophagus: Surveillance every 3-5 years. 1

• Low-grade dysplasia: More frequent surveillance with consideration for radiofrequency ablation after confirmation on two separate endoscopies. 1

• High-grade dysplasia: Endoscopic resection of visible lesions as first-line treatment. 1

Proper Biopsy Protocol

• Non-dysplastic Barrett's: 4-quadrant biopsies every 2 cm of Barrett's segment. 1

• Known dysplasia: 4-quadrant biopsies every 1 cm. 1

• Dysplasia diagnosis must be confirmed by expert gastrointestinal pathologists before initiating treatment. 1

Endoscopic Therapy for Dysplasia

Endoscopic therapy for dysplastic Barrett's esophagus and early adenocarcinoma is cost-effective compared with esophagectomy. 3

Treatment Algorithm by Dysplasia Grade

• Confirmed low-grade dysplasia: Radiofrequency ablation should be offered after confirmation from two separate endoscopies. 1

• High-grade dysplasia: Endoscopic resection of visible lesions as first-line treatment, followed by ablation of residual Barrett's mucosa. 1

• T1a (intramucosal) adenocarcinoma: Endoscopic resection as first-line treatment. 1

• T1b (submucosal) adenocarcinoma: Esophagectomy for patients fit for surgery at high risk of progression. 1

Adjunctive PPI Therapy with Ablation

• Radiofrequency ablation combined with twice-daily PPI therapy is safe and effective, with better ablation efficacy in patients achieving maximal pH control (pH <4 for <4% of time). 5

Chemoprevention Agents

There is insufficient evidence to support the use of aspirin, NSAIDs, or other chemopreventive agents specifically for Barrett's esophagus. 3, 1

• Patients should be screened for cardiovascular risk factors for which aspirin might be indicated for other reasons, as cardiovascular deaths are more common than esophageal adenocarcinoma deaths in Barrett's patients. 1, 2

Long-term Outcomes with PPI Therapy

• Long-term PPI treatment (up to 13 years) does not cause significant regression of Barrett's segment length, but squamous islands appear in 48-100% of patients over time. 6, 7

• The incidence of esophageal adenocarcinoma in PPI-treated patients was 0.31% in one long-term study, which is low compared to published series. 7

Key Clinical Caveats

• Do not attempt to eliminate esophageal acid exposure through high-dose PPIs or antireflux surgery solely for cancer prevention - this approach lacks evidence and is not recommended. 1

• Do not use endoscopic ultrasonography before endoscopic resection for staging suspected T1a adenocarcinoma. 1

• All management decisions should be discussed with patients in a dedicated appointment, ensuring shared decision-making. 3, 1