From the Guidelines
Barrett's esophagus should be managed with proton pump inhibitors (PPIs) and regular endoscopic surveillance, with frequency depending on the presence of dysplasia, to reduce the risk of developing esophageal adenocarcinoma. The condition is characterized by the replacement of the normal esophageal lining with tissue resembling the lining of the intestine, often due to chronic acid reflux (GERD) damaging the esophageal lining over time 1. Approximately 10% of patients with chronic heartburn symptoms have Barrett's esophagus, which is associated with an increased risk of developing esophageal adenocarcinoma, a type of cancer with a poor prognosis 1.
Key Management Strategies
- Treating the underlying GERD with PPIs such as omeprazole 20-40mg daily or esomeprazole 40mg daily to reduce acid production 1
- Regular endoscopic surveillance, with frequency depending on the presence of dysplasia:
- Every 3-5 years for no dysplasia
- Every 6-12 months for low-grade dysplasia
- Immediate intervention for high-grade dysplasia 1
- Lifestyle modifications, including weight loss if overweight, avoiding meals within 3 hours of bedtime, elevating the head of the bed, and avoiding trigger foods like caffeine, alcohol, chocolate, and fatty foods
- For patients with dysplasia, treatments may include endoscopic procedures like radiofrequency ablation or endoscopic mucosal resection to remove abnormal tissue 1
Surveillance and Treatment
The British Society of Gastroenterology guidelines recommend quadrantic oesophageal biopsies every 2cm for patients with Barrett's esophagus, with the frequency of surveillance depending on the presence of dysplasia and the length of the Barrett's segment 1. The American Gastroenterological Association (AGA) recommends endoscopic eradication therapy for patients with confirmed and persistent low-grade dysplasia, with the goal of achieving complete eradication of intestinal metaplasia 1.
Recent Recommendations
Recent studies have emphasized the importance of expert gastrointestinal pathologist review for the diagnosis of Barrett's esophagus with dysplasia, and the use of high-definition/high-resolution white-light endoscopy for surveillance 1. The AGA also recommends radiofrequency ablation as the preferred method for endoscopic eradication therapy in patients with Barrett's esophagus and dysplasia 1.
From the Research
Definition and Diagnosis of Barrett's Esophagus
- Barrett's esophagus (BE) is a condition that is premalignant for adenocarcinoma of the esophagus and esophagogastric junction 2
- BE is a change in the esophageal epithelium of any length that can be recognized at endoscopy and is confirmed to have intestinal metaplasia by biopsy (American College of Gastroenterology guidelines) 2
- The normal endoscopic anatomy of the esophagogastric junction region and the changes that are associated with BE are discussed, with the relationship of the squamocolumnar mucosal junction to the proximal margin of the gastric folds and the distal extent of the linear esophageal vessels being the principal landmark for diagnosis 3
Surveillance and Management of Barrett's Esophagus
- The American College of Gastroenterology has recommended practice guidelines for surveillance endoscopy, including intervals of every 2 to 3 years for patients with no dysplasia, every 6 months for the first year for patients with low-grade dysplasia, and intensive endoscopic surveillance or esophageal resection for patients with high-grade dysplasia 2
- Endoscopic ablative therapy is recommended for patients with BE and high-grade dysplasia, as well as T1a esophageal adenocarcinoma, and is also recommended for patients with BE and low-grade dysplasia, although endoscopic surveillance continues to be an acceptable alternative 4, 5
- Postablation endoscopic surveillance intervals are suggested, given the relatively common recurrence of BE after ablation 4, 5
Differentiation of High-Grade Dysplasia from Early Adenocarcinoma
- An endoscopic biopsy protocol can differentiate high-grade dysplasia from early adenocarcinoma in Barrett's esophagus, with a systematic acquisition of multiple, large biopsy samples 6
- High-grade dysplasia alone can be differentiated from early adenocarcinoma, and patients with high-grade dysplasia alone in Barrett's esophagus detected by such a protocol do not necessarily require surgical resection to rule out an undiagnosed adenocarcinoma 6