If an esophagogastroduodenoscopy (EGD) no longer shows Barrett's esophagus, is lifelong treatment with proton pump inhibitors (PPI) still necessary in patients who were previously diagnosed with the condition?

From the Guidelines

Patients who previously had Barrett's esophagus should generally continue proton pump inhibitor (PPI) therapy for life, even if a follow-up endoscopy shows resolution of the Barrett's changes. This recommendation is based on the understanding that gastroesophageal reflux disease (GERD) is typically a chronic condition that requires ongoing management. PPIs such as omeprazole (20-40mg daily), esomeprazole (20-40mg daily), pantoprazole (40mg daily), or lansoprazole (30mg daily) help control acid production and prevent recurrence of Barrett's esophagus. The goal is to maintain a non-acidic environment in the esophagus to prevent potential progression to dysplasia or esophageal adenocarcinoma. While the Barrett's changes may have regressed, the underlying reflux condition often persists. Some patients might be candidates for a step-down approach with their gastroenterologist's guidance, potentially reducing to the lowest effective PPI dose that controls symptoms. Regular endoscopic surveillance should also continue according to the recommended schedule based on the patient's risk factors and previous findings, even if Barrett's is no longer visible, as suggested by the American College of Physicians 1. It is essential to note that treatment of Barrett esophagus patients with high doses of acid suppressants solely in the hope of decreasing the risk of adenocarcinoma is of no proven value, as stated in a study published in JAMA 1. However, the primary indication for treating individuals with Barrett esophagus with proton pump inhibitors is the alleviation of reflux symptoms. Key points to consider include:

• The chronic nature of GERD and the need for ongoing management
• The role of PPIs in controlling acid production and preventing recurrence of Barrett's esophagus
• The importance of regular endoscopic surveillance, even if Barrett's is no longer visible
• The potential for a step-down approach in PPI dosage under gastroenterologist guidance.

From the Research

Management of Barrett's Esophagus

• The management of Barrett's esophagus depends on the presence and severity of dysplasia, with endoscopic treatment of dysplasia decreasing the risk of malignant transformation 2.
• Patients with Barrett's esophagus should be offered proton pump inhibitor (PPI) therapy to control reflux symptoms and possibly decrease the risk of developing esophageal adenocarcinoma 2, 3.
• PPI treatment over 1-13 years does not shorten the Barrett's esophagus segment but squamous islands appear in many patients, and the incidence of oesophageal adenocarcinoma was low in these PPI-treated patients compared with published series 4.

Discontinuation of PPI Therapy

• There is no clear evidence to suggest that PPI therapy can be discontinued in patients with Barrett's esophagus, even if the condition is no longer visible on endoscopy 5, 6.
• The risk of esophageal adenocarcinoma in patients with Barrett's esophagus is still present, even if the condition is no longer visible, and PPI therapy may still be beneficial in reducing this risk 3.

Surveillance and Treatment

• Surveillance after diagnosis is recommended to monitor for dysplasia and diagnose and treat esophageal adenocarcinoma at an earlier stage 2, 6.
• Endoscopic eradication therapy is recommended for patients with Barrett's esophagus and high-grade dysplasia, and those with Barrett's esophagus and low-grade dysplasia 6.