What is the recommended diagnosis, treatment, and surveillance strategy for Barrett's esophagus?

Barrett's Esophagus: Diagnosis, Treatment, and Surveillance

Diagnosis and Initial Assessment

All patients with newly diagnosed Barrett's esophagus should undergo high-resolution white light endoscopy with Seattle biopsy protocol (4-quadrant biopsies every 2 cm throughout the Barrett's segment, plus targeted biopsies of any visible lesions). 1

• Document the extent of Barrett's using the Prague classification system, recording both the circumferential (C) and maximal (M) extent of columnar-lined esophagus 1
• Obtain at least two expert gastrointestinal pathologists to confirm any diagnosis of dysplasia, as community pathologists frequently overcall low-grade dysplasia, particularly when inflammation is present 1, 2
• Provide immediate clinical consultation to discuss cancer risk (approximately 0.2-0.5% annual progression to adenocarcinoma), surveillance plans, and symptom control with both verbal and written information 1, 3

Screening Considerations

• Consider screening with upper endoscopy in individuals with at least 3 risk factors: male sex, non-Hispanic white race, age >50 years, smoking history, chronic GERD, obesity, or family history of Barrett's or esophageal adenocarcinoma 1
• Nonendoscopic cell-collection devices may be considered as an alternative screening option 1

Medical Management and Symptom Control

All patients with Barrett's esophagus should be placed on at least daily proton pump inhibitor therapy for symptom control. 1

• Follow NICE guidelines for GERD management as first-line therapy 1, 3
• Do not offer aspirin to prevent progression to dysplasia or cancer 1, 3
• Do not offer anti-reflux surgery specifically to prevent progression to dysplasia or cancer, as it is not more effective than medical therapy 4, 3

Surveillance Strategy Based on Dysplasia Status

Non-Dysplastic Barrett's Esophagus

Perform surveillance endoscopy every 3-5 years using high-resolution white light endoscopy with Seattle biopsy protocol. 1, 3

• For Barrett's segments <3 cm, surveillance every 5 years is appropriate 5
• For Barrett's segments 3-10 cm, surveillance every 3 years is recommended 5
• For Barrett's segments ≥10 cm, refer to a Barrett's expert center 5
• Consider discontinuing surveillance if the patient reaches 75 years of age or has life expectancy <5 years 5

Indefinite for Dysplasia

Perform endoscopic surveillance at 6-month intervals with dose optimization of acid-suppressant medication (typically twice-daily PPI therapy for 8 weeks to reduce inflammation). 1, 3

• Repeat endoscopy after optimizing acid suppression, as inflammation can mimic dysplasia 1

Low-Grade Dysplasia

Confirm the diagnosis with biopsy samples from two separate endoscopies, verified by two expert gastrointestinal pathologists, then offer radiofrequency ablation. 1, 2, 3

• This two-endoscopy, two-pathologist confirmation requirement is critical because low-grade dysplasia has an extremely high false-positive rate in community practice 2
• For patients who decline or defer radiofrequency ablation, perform surveillance endoscopy at 6-12 month intervals 2
• Continue PPI therapy during surveillance, though not specifically for cancer prevention 2

High-Grade Dysplasia

Offer endoscopic resection of visible oesophageal lesions as first-line treatment, followed by endoscopic ablation of any residual Barrett's esophagus. 1, 4, 3

• For high-grade dysplasia without visible lesions, offer endoscopic ablation to prevent progression to invasive cancer 5
• Radiofrequency ablation is the preferred ablation modality 1
• Provide endoscopic follow-up to all patients who receive endoscopic treatment 1

Management of Stage 1 Oesophageal Adenocarcinoma

T1a Adenocarcinoma

Offer endoscopic resection as first-line treatment, followed by endoscopic ablation of any residual Barrett's esophagus. 1, 4, 3

• Endoscopic resection is curative for T1a cancer with well/moderate differentiation and no lymphovascular invasion 5
• Do not use CT before endoscopic resection for staging suspected T1 adenocarcinoma 1, 3
• Do not use endoscopic ultrasonography (EUS) before endoscopic resection for staging suspected T1a adenocarcinoma 1

T1b Adenocarcinoma

For patients fit for surgery with high-risk features (submucosal invasion >500 µm, lymphovascular invasion, or poor differentiation), offer oesophagectomy. 4, 3, 5

• Consider EUS for nodal staging based on endoscopic appearances or histological examination 1, 3
• Low-risk T1b cancer (submucosal invasion ≤500 µm AND no lymphovascular invasion AND no poor differentiation) can be treated endoscopically with close follow-up in expert centers 5
• For patients unfit for oesophagectomy but at high risk of progression, consider radiotherapy alone or combined with chemotherapy 4, 3
• High-risk T1b adenocarcinoma requires multidisciplinary discussion for additional treatments (chemotherapy, radiotherapy, or surgery) 5

Post-Treatment Surveillance After Endoscopic Eradication Therapy

Perform the first endoscopic follow-up in an expert center with careful inspection of the neo-squamocolumnar junction and neo-squamous epithelium using high-definition white light endoscopy and virtual chromoendoscopy. 5

• Obtain four-quadrant random biopsies just distal to the neo-squamocolumnar junction to detect dysplasia 5
• Do not perform routine four-quadrant biopsies of neo-squamous epithelium 5
• Obtain targeted biopsies where there is suspicion of recurrent Barrett's or visible lesions 5
• Take random biopsies of the esophagogastric junction, gastric cardia, and distal 2 cm of neosquamous epithelium, plus all visible lesions 1

Surveillance Intervals After Successful Eradication

For patients with baseline high-grade dysplasia or adenocarcinoma: surveillance at 1,2,3,4,5,7, and 10 years after last treatment, then stop. 5

For patients with baseline low-grade dysplasia: surveillance at 1,3, and 5 years after last treatment, then stop. 5

Critical Pitfalls to Avoid

• Never proceed with ablation based on a single pathologist's diagnosis or single endoscopy for low-grade dysplasia - the false-positive rate is extremely high 2
• Never recommend aspirin or anti-reflux surgery specifically for cancer prevention - evidence does not support these interventions 1, 2, 3
• Never use CT or EUS before endoscopic resection for T1a staging - endoscopic resection itself provides the most accurate staging 1, 3
• Ensure patients with dysplasia or neoplasia are referred to endoscopists with expertise in advanced imaging, resection, and ablation 1
• Always optimize acid suppression before diagnosing dysplasia, as inflammation can mimic dysplastic changes 1