What is the treatment for Barrett's esophagus?

Treatment for Barrett's Esophagus

Treatment of Barrett's esophagus is stratified by the presence and grade of dysplasia, with proton pump inhibitors (PPIs) for symptom control in all patients, endoscopic surveillance for non-dysplastic disease, radiofrequency ablation for low-grade dysplasia, and endoscopic resection followed by ablation for high-grade dysplasia or early cancer. 1

Medical Management for Non-Dysplastic Barrett's Esophagus

PPIs are the cornerstone of medical therapy for Barrett's esophagus, but should be used primarily for symptom control of gastroesophageal reflux disease (GERD), not for cancer prevention. 2, 3

• Follow standard GERD treatment recommendations with PPIs to control reflux symptoms 1
• Do not use high-dose PPI therapy solely to prevent progression to dysplasia or cancer, as there is insufficient evidence to support this approach 2, 4
• Do not offer aspirin specifically to prevent progression to esophageal dysplasia and cancer 1
• Antireflux surgery is not superior to medical therapy for preventing neoplastic progression and should not be offered for this purpose 2, 3
• Consider antireflux surgery only in patients with poor or partial symptomatic response to PPIs 2, 3

Important Caveat on Chemoprevention

While the 2024 NICE guidelines recommend against aspirin for cancer prevention 1, one high-quality 2018 randomized trial (AspECT) showed that combining high-dose PPI (40 mg twice daily) with aspirin significantly improved outcomes compared to low-dose PPI without aspirin (time ratio 1.59, p=0.0068), with a number needed to treat of 43 for aspirin 5. However, current guidelines have not incorporated this as a standard recommendation, and aspirin should only be considered if indicated for cardiovascular risk factors 2, 3.

Endoscopic Surveillance for Non-Dysplastic Barrett's Esophagus

All patients with Barrett's esophagus require endoscopic surveillance to monitor for progression to dysplasia and adenocarcinoma. 2, 4

• Offer high-resolution white light endoscopy with Seattle biopsy protocol for surveillance 1
• Surveillance intervals: every 3-5 years for non-dysplastic Barrett's esophagus 2, 4
• Proper biopsy technique is critical: obtain 4-quadrant biopsies every 2 cm of Barrett's segment for patients without known dysplasia 2, 3, 4
• Discuss benefits and risks of endoscopic surveillance with each patient 1
• Ensure the benefits of surveillance outweigh the risks based on the patient's overall health 1

Management of Low-Grade Dysplasia (LGD)

Offer radiofrequency ablation (RFA) to patients with confirmed low-grade dysplasia diagnosed from biopsy samples taken at two separate endoscopies. 1

• Two gastrointestinal pathologists must confirm the histological diagnosis before proceeding with ablation 1
• RFA leads to reversion to normal-appearing squamous epithelium in 90% of cases 3
• For patients with low-grade dysplasia, obtain biopsies every 1 cm (not every 2 cm as in non-dysplastic disease) 2, 3
• Offer endoscopic follow-up after ablation therapy 1

Management of High-Grade Dysplasia (HGD)

Endoscopic resection of visible oesophageal lesions is the first-line treatment for high-grade dysplasia. 1

• After endoscopic resection, offer endoscopic ablation of any residual Barrett's esophagus 1
• For high-grade dysplasia without visible lesions, endoscopic ablation treatment is recommended to prevent progression to invasive cancer 3
• Up to 50% of patients with high-grade dysplasia have previously unrecognized adenocarcinoma on resection specimens, highlighting the importance of endoscopic resection for accurate staging 1
• Offer endoscopic follow-up after treatment 1

Alternative for Indefinite Dysplasia

• Consider endoscopic surveillance at 6-monthly intervals with dose optimization of acid-suppressant medication for patients diagnosed with indefinite dysplasia 1

Management of Stage 1 Oesophageal Adenocarcinoma

Staging Approach

• Offer endoscopic resection for staging in patients with suspected stage 1 oesophageal adenocarcinoma 1
• Do not use CT before endoscopic resection for staging suspected T1 oesophageal adenocarcinoma 1
• Do not use endoscopic ultrasonography (EUS) before endoscopic resection for staging suspected T1a oesophageal adenocarcinoma 1
• Consider EUS for nodal staging only in patients with suspected or confirmed T1b disease 1

Treatment by T Stage

For T1a (intramucosal) oesophageal adenocarcinoma:

• Offer endoscopic resection as first-line treatment 1, 2
• Offer endoscopic ablation of any residual Barrett's oesophagus after endoscopic resection 1
• Offer endoscopic follow-up after treatment 1

For T1b (submucosal) oesophageal adenocarcinoma:

• Offer oesophagectomy to patients who are fit for surgery and at high risk of cancer progression 1, 2
• Offer a clinical consultation to discuss and evaluate the suitability of treatment options, including endoscopic resection or oesophagectomy 1

Patient Education and Communication

• Provide patients with an endoscopy report that includes a lay summary of findings and reference to ongoing symptom control after each surveillance procedure 1
• When Barrett's esophagus is detected, offer an early outpatient appointment (ideally within 4-6 weeks) to discuss implications, including the low but significant cancer risk (0.2%-0.5% annual rate), lifestyle changes, and surveillance recommendations 4, 6
• Follow recommendations on communication and shared decision-making from relevant patient experience guidelines 1

Critical Pitfalls to Avoid

• Do not attempt to eliminate esophageal acid exposure through high-dose PPIs or antireflux surgery solely for prevention of esophageal adenocarcinoma, as this approach lacks evidence 3, 4
• Do not proceed with ablation therapy for dysplasia without confirmation by expert gastrointestinal pathologists 2
• Do not use EUS routinely before endoscopic resection for T1a disease, as it does not change management 1
• Remember that Barrett's esophagus affects approximately 5% of people in the US, with only 3-5% developing esophageal adenocarcinoma in their lifetime, so avoid overtreatment 6
• Be aware that adenocarcinoma can still develop in patients who have undergone antireflux surgery, so surveillance remains necessary 1