What is the management for Barrett's esophagus?

Management of Barrett's Esophagus

For Barrett's esophagus, use proton pump inhibitors (PPIs) for GERD symptom control, perform endoscopic surveillance every 3-5 years for non-dysplastic disease, and offer endoscopic eradication therapy (radiofrequency ablation or endoscopic mucosal resection) rather than surveillance for confirmed dysplasia. 1, 2

Medical Management for Non-Dysplastic Barrett's Esophagus

Acid Suppression Therapy

• PPIs are the cornerstone of medical therapy for symptom control of GERD in Barrett's esophagus patients, but should not be used solely for cancer prevention. 1, 3
• High-dose PPI therapy (greater than once daily dosing) should not be used to prevent progression to dysplasia or adenocarcinoma, as there is insufficient evidence supporting this approach. 4, 2, 3
• Standard once-daily PPI dosing is appropriate for managing reflux symptoms. 1

Role of Antireflux Surgery

• Antireflux surgery is not superior to medical therapy for preventing neoplastic progression and should not be offered for cancer prevention purposes. 4, 1, 2
• Surgery should only be considered in patients with poor or partial symptomatic response to PPIs for symptom control, not for cancer prevention. 1, 3

Endoscopic Surveillance Protocol

Surveillance Intervals

• Non-dysplastic Barrett's esophagus requires surveillance endoscopy every 3-5 years. 1, 2
• All patients with Barrett's esophagus should undergo endoscopic surveillance to monitor for progression to dysplasia and adenocarcinoma. 1, 3

Biopsy Protocol

• For patients without known dysplasia: obtain 4-quadrant biopsies every 2 cm of the Barrett's segment using white light endoscopy. 4, 1, 2
• For patients with known or suspected dysplasia: obtain 4-quadrant biopsies every 1 cm of the Barrett's segment. 4, 1, 3
• Any visible mucosal irregularities should be biopsied separately and submitted to the pathologist as distinct specimens. 4
• Chromoendoscopy or advanced imaging techniques are not required for routine surveillance. 4

Management of Low-Grade Dysplasia

• Radiofrequency ablation (RFA) should be offered to patients with confirmed low-grade dysplasia diagnosed from biopsy samples taken at two separate endoscopies. 1, 3
• RFA therapy leads to reversion to normal-appearing squamous epithelium in 90% of cases with low-grade dysplasia. 3
• Dysplasia diagnosis should be confirmed by expert gastrointestinal pathologists before initiating treatment. 1

Management of High-Grade Dysplasia

Without Visible Lesions

• Endoscopic eradication therapy with radiofrequency ablation (RFA), photodynamic therapy (PDT), or endoscopic mucosal resection (EMR) is recommended rather than surveillance alone. 4, 2
• Endoscopic ablation prevents progression to invasive cancer in high-grade dysplasia. 3

With Visible Mucosal Irregularities

• Endoscopic mucosal resection (EMR) should be performed first to determine the T stage of the neoplasia. 4, 1, 2
• Following EMR, ablation of any residual Barrett's epithelium should be performed. 1, 3

Management of Early Esophageal Adenocarcinoma

• For T1a (intramucosal) esophageal adenocarcinoma, endoscopic resection should be offered as first-line treatment, followed by ablation of remaining Barrett's epithelium. 1, 3
• For T1b (submucosal) esophageal adenocarcinoma, esophagectomy should be offered to patients who are fit for surgery and at high risk of cancer progression. 1
• Endoscopic ultrasonography (EUS) is not recommended before endoscopic resection for staging suspected T1a esophageal adenocarcinoma. 1

Chemoprevention Considerations

• Aspirin or NSAIDs should not be used solely to prevent esophageal adenocarcinoma in Barrett's esophagus. 4, 1, 3
• However, patients should be screened for cardiovascular risk factors for which aspirin therapy might be indicated for other reasons, as cardiovascular deaths are more common than deaths from esophageal adenocarcinoma among Barrett's patients. 4, 1, 3

Patient Education and Follow-Up

• Patients should receive an early outpatient appointment (ideally within 4-6 weeks of diagnosis) to discuss the low but significant cancer risk (approximately 0.2% to 0.5% annual rate), lifestyle modifications, and surveillance recommendations. 2, 5
• When intervention is considered, therapeutic options should be discussed with both an endoscopist and a surgeon. 1

Critical Pitfalls to Avoid

• Do not attempt to eliminate esophageal acid exposure through high-dose PPIs, pH monitoring to titrate PPI dosing, or antireflux surgery solely for cancer prevention—this approach lacks supporting evidence. 4, 2, 3
• Do not use cryotherapy for confirmed dysplasia, as it currently lacks adequate evidence to assess its ability to achieve sustained reversion to squamous epithelium. 3
• Do not rely on biomarkers to confirm dysplasia diagnosis or predict progression risk, as they cannot be recommended at this time. 4
• Be aware that increased serum Chromogranin A (CgA) levels from PPI therapy may cause false positive results in diagnostic investigations for neuroendocrine tumors. 6