Surveillance Interval for Barrett's Esophagus Without Dysplasia
For patients with Barrett's esophagus without dysplasia, perform surveillance endoscopy every 3-5 years for short segments (<3 cm) and every 2-3 years for long segments (≥3 cm). 1, 2
Surveillance Intervals Based on Segment Length
The surveillance interval should be stratified by the length of Barrett's segment using the Prague classification:
- Short segment (<3 cm): Surveillance every 3-5 years 1, 2, 3
- Long segment (≥3 cm to <10 cm): Surveillance every 2-3 years 1, 2, 3
- Very long segment (≥10 cm): Refer to a Barrett's expert center for surveillance 3, 4
The British Society of Gastroenterology specifically recommends the more frequent 2-3 year interval for segments ≥3 cm, while the American Gastroenterological Association uses the broader 3-5 year recommendation for all non-dysplastic Barrett's 1. The European Society of Gastrointestinal Endoscopy (ESGE) provides the most granular approach with 5-year intervals for 1-3 cm segments and 3-year intervals for 3-10 cm segments 3.
Essential Biopsy Protocol During Surveillance
Adherence to proper biopsy technique is critical, as studies demonstrate that following recommended protocols significantly increases dysplasia detection rates 1, 2:
- Four-quadrant biopsies every 2 cm throughout the Barrett's segment 1, 2
- Targeted biopsies of any visible mucosal irregularities, submitted separately 1, 2
- High-definition white light endoscopy should be used 1, 2, 3
- Document extent using Prague classification (circumferential and maximal extent) 2, 3
Special Considerations for Very Short Segments
For patients with Barrett's <3 cm without intestinal metaplasia on initial biopsy 1:
- Perform a confirmatory endoscopy with repeat four-quadrant biopsies 1
- If repeat endoscopy confirms absence of intestinal metaplasia, consider discharge from surveillance as endoscopy risks may outweigh benefits 1
For irregular Z-line or columnar-lined esophagus <1 cm, no routine biopsies or surveillance are recommended 3, 4.
When to Consider Stopping Surveillance
Surveillance may be discontinued when 3:
- Patient reaches 75 years of age at time of last surveillance, OR
- Patient's life expectancy is <5 years 3
These decisions should account for patient fitness for repeat endoscopies and overall health status 1.
Critical Pitfalls to Avoid
Inadequate biopsy sampling is the most common error leading to missed dysplasia 1, 2. Many gastroenterologists fail to adhere to the Seattle protocol (four-quadrant biopsies every 2 cm), with adherence being poorest in patients with extensive Barrett's metaplasia who are paradoxically at highest risk 1.
Do not perform surveillance biopsies in the presence of active esophagitis 5. Inflammation can lead to overcalling of dysplasia by pathologists 1. Optimize acid suppression first with proton pump inhibitors, then repeat endoscopy after inflammation resolves 5.
All patients should be on at least daily proton pump inhibitor therapy during surveillance 2, though anti-reflux surgery is not recommended specifically to prevent progression to dysplasia 6.
If any degree of dysplasia is detected, the diagnosis must be confirmed by an expert GI pathologist before altering management, as there is significant interobserver variability in dysplasia diagnosis 1, 2, 5, 4.