Treatment for Barrett's Esophagus Without Dysplasia
For Barrett's esophagus without dysplasia, use proton pump inhibitors (PPIs) once daily for symptom control of GERD, implement endoscopic surveillance every 3-5 years, and avoid high-dose PPIs or antireflux surgery for cancer prevention as these approaches lack proven benefit. 1, 2
Medical Management
Proton Pump Inhibitor Therapy
PPIs are the cornerstone of medical therapy for Barrett's esophagus without dysplasia, but should be prescribed specifically for symptom control of GERD, not for cancer prevention. 1, 2
Standard once-daily PPI dosing is appropriate, with the dose guided by reflux symptoms rather than attempting to eliminate all acid exposure. 3
High-dose PPI therapy (greater than once daily) or pH monitoring to titrate PPI dosing should not be used solely to prevent progression to adenocarcinoma, as this approach has no proven value in preventing cancer. 4, 1
While one observational study suggested PPIs may reduce dysplasia risk 5, the highest quality guideline evidence from the American Gastroenterological Association clearly states that attempts to eliminate esophageal acid exposure through escalated PPI dosing are not recommended for cancer prevention. 4, 1
Role of Antireflux Surgery
Antireflux surgery is not superior to medical therapy for preventing neoplastic progression and should not be offered for this purpose. 1, 2
Surgery should only be considered in patients with poor or partial symptomatic response to PPIs, not as a cancer prevention strategy. 1, 2
Long-term data demonstrate no significant difference in cancer development between medically and surgically treated patients (4% vs 3% over nearly 10 years), and adenocarcinoma can still develop after antireflux procedures. 4
Endoscopic Surveillance Strategy
Surveillance Intervals
All patients with Barrett's esophagus without dysplasia require endoscopic surveillance every 3-5 years to monitor for progression to dysplasia and adenocarcinoma. 1, 3
Surveillance intervals may be stratified by Barrett's segment length, with every 2-3 years for long segment (≥3 cm) and every 3-5 years for short segment (<3 cm). 3
Biopsy Protocol
Perform 4-quadrant biopsies every 2 cm of the Barrett's segment using white light endoscopy. 4, 1
Submit specific biopsy specimens of any mucosal irregularities separately to the pathologist. 4
Chromoendoscopy or advanced imaging techniques are not required for routine surveillance of non-dysplastic Barrett's esophagus. 4
What NOT to Do: Common Pitfalls
Avoid Unproven Interventions
Do not attempt endoscopic ablation therapy (radiofrequency ablation, photodynamic therapy, multipolar electrocoagulation) in non-dysplastic Barrett's esophagus. 4
These ablative modalities remain experimental for non-dysplastic disease, and given the low annual cancer risk (0.2-0.5%), they are not justified. 4, 6
Ablation carries risks including incomplete reversion with residual Barrett's mucosa beneath squamous epithelium, and adenocarcinoma has been reported developing beneath apparently normal squamous epithelium after ablation. 4
Chemoprevention
Do not prescribe aspirin or NSAIDs solely to prevent esophageal adenocarcinoma, as the potential benefit does not clearly outweigh medication risks. 4
However, screen patients for cardiovascular risk factors for which aspirin therapy may be indicated for other reasons, as cardiovascular deaths are more common than esophageal adenocarcinoma deaths in this population. 4, 1
Patient Education
Inform patients that Barrett's esophagus carries a low but significant cancer risk, with approximately 3-5% lifetime risk of developing esophageal adenocarcinoma. 6
Emphasize that the annual rate of progression to cancer is only 0.2-0.5%, making aggressive interventions beyond surveillance inappropriate for non-dysplastic disease. 6
Discuss the importance of adherence to surveillance intervals and PPI therapy for symptom control. 3