What is the treatment approach for a patient over 50 with a history of chronic Gastroesophageal Reflux Disease (GERD) symptoms and diagnosed with Barrett's esophagus?

Treatment of Barrett's Esophagus

For a patient over 50 with chronic GERD and diagnosed Barrett's esophagus without dysplasia, initiate proton pump inhibitor (PPI) therapy at standard doses (omeprazole 20 mg once daily) and establish endoscopic surveillance every 3-5 years. 1

Medical Management

Acid Suppression Therapy

• Start PPI therapy as the cornerstone of treatment for all patients with Barrett's esophagus to control acid exposure and prevent progression of esophagitis 1, 2
• Omeprazole 20 mg once daily taken before meals is the standard initial dose for GERD maintenance therapy 2
• Titrate to the lowest effective dose that controls symptoms while maintaining healing 1
• Critical caveat: Despite aggressive acid suppression with PPIs or H2-blockers, medical therapy does NOT reliably cause regression of Barrett's epithelium and does NOT prevent progression to dysplasia or adenocarcinoma 3, 4

Role of Antireflux Surgery

• Surgical fundoplication does NOT eliminate Barrett's mucosa or prevent cancer development, even when symptomatic control is excellent 1, 3
• Surgery may be considered for patients with large hiatal hernias or voluminous reflux, but surveillance remains mandatory post-operatively 5
• Cases of adenocarcinoma have been reported in patients who underwent antireflux surgery months to years prior 1

Surveillance Strategy Based on Dysplasia Status

No Dysplasia (Your Patient's Category)

• Perform surveillance endoscopy every 3-5 years using high-resolution white light endoscopy 1
• Use the Seattle protocol: quadrantic biopsies every 2 cm throughout the Barrett's segment, plus targeted biopsies of any visible lesions 1
• Document Barrett's length using Prague criteria (C and M measurements) 1
• Do NOT perform surveillance more frequently than every 3 years in non-dysplastic Barrett's, as this exposes patients to unnecessary procedures without improving outcomes 1

Low-Grade Dysplasia

• Increase surveillance frequency (specific intervals determined by expert pathology review) 1
• All dysplasia diagnoses must be confirmed by a second gastrointestinal pathologist 1

High-Grade Dysplasia

• Endoscopic eradication therapy is indicated using ablation (radiofrequency ablation), endoscopic mucosal resection, or both 6
• Cancer risk exceeds 25% in high-grade dysplasia 1
• Multidisciplinary team discussion is mandatory 1

Patient Education and Shared Decision-Making

Essential Counseling Points

• Explain that Barrett's esophagus carries approximately 0.5% annual risk of progression to adenocarcinoma 1
• Discuss that surveillance aims to detect dysplasia or early cancer when curative treatment is possible 1
• Emphasize that PPI therapy controls symptoms and heals esophagitis but does not eliminate Barrett's tissue 3, 4
• Address lifestyle modifications: weight management, dietary changes, and smoking cessation (smoking is a risk factor for progression) 1

Surveillance Decision-Making

• Consider patient's life expectancy and fitness for repeat endoscopies when deciding whether surveillance is appropriate 1
• Patients with significant comorbidities limiting life expectancy may not benefit from surveillance 1
• Provide written information about Barrett's esophagus and arrange early outpatient clinic access for discussion 1

What NOT to Do

Avoid These Common Pitfalls

• Do NOT use advanced imaging techniques (chromoendoscopy or virtual chromoendoscopy) for routine surveillance, as they are not superior to white light endoscopy 1
• Do NOT pursue experimental ablation therapies (laser, photodynamic therapy, argon plasma coagulation) in non-dysplastic Barrett's, as these remain investigational and cancer can develop beneath treated areas 1, 3, 4
• Do NOT discontinue surveillance after antireflux surgery, as cancer risk persists 1, 3
• Do NOT perform surveillance more frequently than recommended without dysplasia, as this increases costs and procedural risks without benefit 1

Monitoring Long-Term PPI Therapy

• If PPI therapy continues beyond 12 months without objective confirmation of GERD, offer endoscopy with prolonged wireless pH monitoring off PPI to establish appropriate long-term management 1
• After initial endoscopy confirms Barrett's esophagus, routine repeat endoscopy is not indicated outside the 3-5 year surveillance schedule unless dysplasia develops 1, 7
• Reassess PPI dosing annually and attempt to use the lowest effective dose 1