What follow-up is needed after an Esophagogastroduodenoscopy (EGD) for a patient with a history of Barrett's esophagus?

Follow-Up After EGD for Barrett's Esophagus

Yes, ongoing endoscopic surveillance is required after EGD for Barrett's esophagus, with the frequency determined by the presence and grade of dysplasia found on biopsy. 1, 2

Surveillance Intervals Based on Findings

Non-Dysplastic Barrett's Esophagus

• Short segment (<3 cm): Repeat EGD every 3-5 years 2
• Long segment (≥3 cm): Repeat EGD every 2-3 years 1, 2
• All patients should be maintained on at least daily proton pump inhibitor therapy 2

Low-Grade Dysplasia (LGD)

• Confirm diagnosis with a second expert GI pathologist due to significant interobserver variability 2
• Repeat high-definition EGD within 3-6 months to exclude visible lesions requiring endoscopic resection 1
• If confirmed and persistent LGD: Repeat EGD at 6-12 months, then consider either continued surveillance or endoscopic eradication therapy 1, 2
• If no endoscopic therapy performed: First EGD at 12 months, second at 2 years, then annually 1

High-Grade Dysplasia (HGD)

• Confirm with expert pathologist and perform high-resolution endoscopy to detect any visible lesions 1
• If flat HGD without visible lesions: Endoscopic ablative therapy (radiofrequency ablation) is preferred over surveillance alone 1
• If no endoscopic therapy: Repeat EGD every 3 months 1
• After successful eradication therapy: Follow-up at 3,6, and 12 months, then annually thereafter 2

After Endoscopic Therapy (Resection or Ablation)

• Wait 2-3 months after endoscopic resection for ulcer healing before starting ablation therapy of residual Barrett's 1
• Repeat EGD and ablation every 2-3 months until complete eradication of intestinal metaplasia is achieved 1
• Endoscopic follow-up is mandatory after endoscopic therapy, with biopsies taken from the gastroesophageal junction and within the extent of previous Barrett's esophagus 1
• For T1a esophageal adenocarcinoma after curative resection: First EGD at 6 months, then every 6 months for 2 years, then annually 1, 2

Critical Biopsy Protocol Requirements

The Seattle protocol must be followed to avoid inadequate sampling and missed dysplasia 2:

• Use high-definition white-light endoscopy with Prague classification documentation (circumferential and maximal extent) 1, 2
• Obtain 4-quadrant biopsies every 2 cm of Barrett's segment for non-dysplastic cases 1, 2
• Obtain 4-quadrant biopsies every 1 cm for known or suspected dysplasia 2
• Take targeted biopsies of any visible lesions or mucosal abnormalities first, before random biopsies 1

Key Clinical Pitfalls to Avoid

• Never perform ablation without first resecting visible lesions, as ablation does not allow pathologic staging to assess depth of invasion and lymph node metastasis risk 1
• Do not ablate inflamed Barrett's mucosa—ablation should only be performed on flat Barrett's without inflammation and in the absence of visible abnormalities 1
• Eradication of residual Barrett's after focal endoscopic resection is essential, as more than 20% of patients develop metachronous lesions within 2 years if residual Barrett's is not ablated 1
• All dysplasia requires confirmation by a second expert GI pathologist before making treatment decisions 1, 2
• Surveillance should continue lifelong even after successful eradication therapy, as recurrent Barrett's (including subsquamous columnar epithelium) can develop and require further treatment 1

When to Refer for Specialized Care

• All patients with dysplasia or early cancer should be discussed at a multidisciplinary team including an interventional endoscopist, upper GI surgeon, radiologist, and GI pathologist 1
• Endoscopic therapy should be performed only in high-volume centers performing a minimum of 10 new cases annually 1