What is the management approach for a patient with a raised area within Barrett's (Barrett's esophagus) esophagus suspicious for dysplasia?

Management of Raised Area Within Barrett's Esophagus Suspicious for Dysplasia

Any visible lesion within Barrett's esophagus must undergo endoscopic mucosal resection (EMR) first to accurately determine the true grade of dysplasia before any other management decisions are made. 1, 2

Immediate Management Steps

Step 1: Perform Endoscopic Mucosal Resection

• EMR is mandatory for all visible mucosal abnormalities (no matter how subtle) within Barrett's esophagus to accurately assess the T stage and true grade of dysplasia. 1, 2
• Target biopsies of visible lesions should be obtained first, submitted separately from random surveillance biopsies. 1
• The raised area may harbor higher-grade dysplasia or early adenocarcinoma that would be missed on standard biopsy—areas of high-grade dysplasia and microscopic carcinoma are often small (median 1.3 sq cm and 1.1 sq cm respectively). 3

Step 2: Optimize Acid Suppression Before Biopsy

• Ensure the patient is on twice-daily proton pump inhibitor (PPI) therapy for 8-12 weeks before performing biopsies. 1
• Do not perform surveillance biopsies in the presence of active erosive esophagitis (Los Angeles grade C or D), as inflammation can lead to overdiagnosis of dysplasia. 1, 4
• If erosive esophagitis is present, intensify acid suppression and repeat endoscopy after complete healing. 1, 4

Step 3: Obtain Expert Pathology Confirmation

• The diagnosis of dysplasia must be confirmed by an expert gastrointestinal pathologist before proceeding with any treatment decisions. 1, 2
• This is critical because there is significant interobserver variability among pathologists in diagnosing dysplasia. 1
• If the diagnosis is downgraded to non-dysplastic Barrett's esophagus, manage as non-dysplastic disease with surveillance every 3-5 years. 1, 2

Subsequent Management Based on EMR Results

If Low-Grade Dysplasia (LGD) is Confirmed:

• Repeat high-definition endoscopy in 8-12 weeks under maximal acid suppression. 1
• Perform four-quadrant biopsies every 1-2 cm throughout the Barrett's segment. 1
• Offer radiofrequency ablation (RFA) after EMR of the visible lesion, as RFA significantly reduces progression to high-grade dysplasia or adenocarcinoma (OR: 0.17,95% CI: 0.04-0.65). 2
• If surveillance is chosen instead of ablation, perform endoscopy every 6 months for the first year, then annually. 2

If High-Grade Dysplasia (HGD) is Confirmed:

• Endoscopic eradication therapy with RFA, photodynamic therapy (PDT), or EMR is strongly recommended rather than surveillance alone. 1
• The goal is complete eradication of all intestinal metaplasia to prevent progression to adenocarcinoma. 1, 2
• After complete eradication, perform surveillance endoscopy annually for 2 years, then every 3 years. 2

If Intramucosal Adenocarcinoma (T1a) is Found:

• EMR alone may be curative for T1a lesions. 1
• Follow-up surveillance should be performed every 3 months for 1 year, then annually. 1

Critical Referral Requirements

• All patients with confirmed dysplasia and visible lesions must be referred to an endoscopist with expertise in managing Barrett's esophagus-related neoplasia. 1, 2
• The referral center must be equipped with high-definition endoscopy and capable of performing both endoscopic resection and ablation. 1, 2

Common Pitfalls to Avoid

• Never ablate a visible lesion without first performing EMR—ablation destroys tissue needed for accurate histologic staging and may miss invasive cancer. 1, 2
• Do not rely on community pathology alone for dysplasia diagnosis—always obtain expert GI pathology confirmation. 1, 2
• Do not perform biopsies during active severe esophagitis, as inflammatory changes can mimic dysplasia. 1, 4
• Do not use standard biopsy forceps alone for raised lesions—EMR provides both therapeutic resection and accurate staging. 1, 3