What is the recommended frequency for Esophagogastroduodenoscopy (EGD) surveillance in patients with Barrett's esophagus, with or without dysplasia?

EGD Surveillance Frequency for Barrett's Esophagus

For patients with non-dysplastic Barrett's esophagus, perform surveillance endoscopy every 3-5 years; for low-grade dysplasia, every 6-12 months initially then annually; and for high-grade dysplasia without ablation, every 3 months. 1

Non-Dysplastic Barrett's Esophagus

Surveillance intervals should be every 3-5 years for patients without dysplasia. 1, 2 This recommendation represents a shift from older, more frequent surveillance protocols, acknowledging the relatively low annual cancer risk (0.5-1.9%) in this population. 3, 4

• The British Society of Gastroenterology refines this further based on Barrett's segment length: short segments (<3 cm) warrant surveillance every 3-5 years, while long segments (≥3 cm) should be surveilled every 2-3 years. 1, 2
• The European Society of Gastrointestinal Endoscopy (ESGE) 2023 guidelines suggest even more extended intervals: every 5 years for BE 1-3 cm and every 3 years for BE 3-10 cm. 5

During each surveillance endoscopy, obtain 4-quadrant biopsies every 2 cm throughout the Barrett's segment using high-definition white light endoscopy. 1, 2 Any visible mucosal irregularities require separate targeted biopsies submitted in distinct containers. 1

Low-Grade Dysplasia

The diagnosis of low-grade dysplasia must first be confirmed by an expert GI pathologist before determining surveillance intervals. 1, 6 Community pathologists frequently overcall dysplasia, particularly when esophageal inflammation is present. 1, 6

Once confirmed by expert pathology review:

• Repeat endoscopy within 8-12 weeks under maximal acid suppression to confirm persistent dysplasia. 1
• If low-grade dysplasia persists, surveillance should be performed every 6 months for the first year, then annually thereafter. 1, 6
• Obtain 4-quadrant biopsies every 1-2 cm (more frequent than non-dysplastic BE) along with targeted biopsies of any visible lesions. 1, 2

Importantly, endoscopic eradication therapy with radiofrequency ablation is now the preferred management for confirmed, persistent low-grade dysplasia rather than surveillance alone. 1, 6 This recommendation is based on level 1 evidence showing RFA significantly reduces progression to high-grade dysplasia or adenocarcinoma (OR 0.17,95% CI 0.04-0.65). 6, 4

High-Grade Dysplasia

For patients with high-grade dysplasia who are not undergoing endoscopic eradication therapy, surveillance should occur every 3 months. 1, 2

However, endoscopic ablation is now strongly recommended for high-grade dysplasia without visible lesions to prevent progression to invasive cancer. 5, 4 Surveillance every 3 months is reserved only for those rare patients who decline or are not candidates for ablation therapy.

Post-Ablation Surveillance

After successful endoscopic eradication therapy achieving complete eradication of intestinal metaplasia, perform surveillance endoscopy annually for 2 years, then every 3 years thereafter. 1, 6

The ESGE provides more granular post-ablation surveillance based on baseline histology: 5

• For baseline high-grade dysplasia or adenocarcinoma: surveillance at 1,2,3,4,5,7, and 10 years after last treatment
• For baseline low-grade dysplasia: surveillance at 1,3, and 5 years after last treatment

During post-ablation surveillance, obtain 4-quadrant biopsies every 2 cm and targeted biopsies of any visible abnormalities, but routine biopsies of normal-appearing neo-squamous epithelium are not recommended. 2, 5

Critical Quality Standards

All surveillance endoscopies must be performed using high-definition white light endoscopy with documentation of the Prague classification (circumferential and maximal extent). 2, 5, 4

Minimum inspection time should be at least 1 minute per cm of Barrett's length. 5

Common Pitfalls to Avoid

• Never perform surveillance biopsies in the presence of active erosive esophagitis - optimize acid suppression first and repeat after inflammation resolves, as inflammation causes pathologists to overcall dysplasia. 1, 6
• Do not rely on community pathology alone for dysplasia diagnosis - always obtain expert GI pathology confirmation before making management decisions. 1, 6
• Avoid inadequate biopsy sampling - adherence to the Seattle protocol (4-quadrant biopsies every 2 cm) is associated with significantly higher dysplasia detection rates. 1, 2
• Consider discontinuing surveillance in patients ≥75 years old or with life expectancy <5 years, as the benefit of continued surveillance diminishes. 5