What is the recommended management for Barrett's esophagus, including proton pump inhibitor therapy, lifestyle modifications, surveillance intervals, and treatment options for non‑dysplastic, low‑grade dysplasia, and high‑grade dysplasia?

Management of Barrett's Esophagus

Offer proton pump inhibitor therapy at least once daily to all patients with Barrett's esophagus for symptom control, but do not use high-dose PPIs or antireflux surgery solely to prevent cancer progression, as these strategies have not been proven effective for chemoprevention. 1

Pharmacological Management

Acid Suppression for Symptom Control

• Prescribe at least daily PPI therapy for all patients with Barrett's esophagus to control gastroesophageal reflux symptoms. 2, 3
• The dose should be titrated to symptom control and reviewed regularly to assess for side effects including bone fractures, infections, and electrolyte disturbances. 1
• High-dose PPIs (twice daily) showed no clinically important effect on all-cause mortality, progression to dysplasia or cancer, or serious adverse events in randomized controlled trials. 1

Chemoprevention: What NOT to Do

• Do not offer aspirin solely to prevent esophageal adenocarcinoma in the absence of other cardiovascular indications. 1
• Do not use high-dose PPIs, pH monitoring to titrate PPI dosing, or antireflux surgery for cancer prevention—these approaches lack evidence for reducing adenocarcinoma risk. 1, 3
• Antireflux surgery is not more effective than medical GERD therapy for preventing cancer in Barrett's esophagus. 1, 3

Endoscopic Surveillance Strategy

Non-Dysplastic Barrett's Esophagus

• Perform surveillance endoscopy every 3-5 years using high-definition white-light endoscopy with the Seattle biopsy protocol. 2, 3
• Obtain four-quadrant biopsies every 2 cm throughout the Barrett's segment in patients without known dysplasia. 2, 3
• Document the extent using Prague classification (circumferential and maximal extent of columnar-lined esophagus). 1, 2

Low-Grade Dysplasia Management

• Repeat endoscopy in 8-12 weeks under maximal acid suppression (twice-daily PPI) after initial diagnosis to exclude inflammation-related over-diagnosis and confirm the diagnosis. 1, 2
• The confirming endoscopy should be performed by an endoscopist experienced in managing dysplastic Barrett's esophagus. 1
• Obtain four-quadrant biopsies every 1 cm for patients with known or suspected dysplasia. 1, 2
• Consider radiofrequency ablation (RFA) after confirming low-grade dysplasia, as it significantly reduces progression to high-grade dysplasia or adenocarcinoma (OR: 0.17). 4

High-Grade Dysplasia Management

• Strongly recommend endoscopic eradication therapy with radiofrequency ablation, photodynamic therapy, or endoscopic mucosal resection rather than surveillance alone. 1, 2, 3
• The goal is complete eradication of all intestinal metaplasia to prevent progression to adenocarcinoma. 2, 4
• Patients with high-grade dysplasia have a risk of subsequent adenocarcinoma exceeding 25%, and up to 50% of esophagectomy specimens show previously unrecognized adenocarcinoma. 1

Critical Technical Requirements

Endoscopic Technique

• Use high-definition white-light endoscopy with virtual chromoendoscopy as the standard of care for all screening and surveillance examinations. 1, 2
• Clean the mucosa thoroughly and remove all debris before inspection. 1
• Spend adequate time inspecting the entire Barrett's segment, as a 25.3% missed esophageal adenocarcinoma rate has been reported within 1 year of initial endoscopy. 1

Biopsy Protocol

• Always obtain target biopsies FIRST from any visible lesions (nodularity, ulceration, plaques, areas of depression, strictures, mucosal discoloration) and submit them separately from random surveillance biopsies. 1, 2, 4
• For any visible mucosal irregularity, perform endoscopic mucosal resection (EMR) to determine the T stage before any ablation therapy. 1, 2, 4
• Never ablate a visible lesion without first performing EMR, as ablation destroys tissue needed for accurate histologic staging and may miss invasive cancer. 4

Pathology Confirmation

• All dysplasia diagnoses must be confirmed by expert gastrointestinal pathology review due to significant interobserver variability among pathologists. 2, 4
• Do not perform surveillance biopsies in the presence of active erosive esophagitis (Los Angeles grade C or D); intensify acid suppression with twice-daily PPI for 8-12 weeks and repeat endoscopy after healing. 1, 4

Post-Eradication Surveillance

Follow-Up Schedule

• After achieving complete eradication of intestinal metaplasia, perform surveillance endoscopy annually for 2 years, then every 3 years thereafter. 2
• Obtain biopsies from the esophagogastric junction, gastric cardia, distal 2 cm of neosquamous epithelium, and all visible lesions regardless of original Barrett's length. 2

Referral Requirements

• Refer all patients with confirmed dysplasia and visible lesions to an endoscopist with expertise in managing Barrett's esophagus-related neoplasia, with access to high-definition endoscopy and capability to perform both endoscopic resection and ablation. 4

Patient Education

• Offer a clinical consultation following diagnosis to provide information about the low but significant cancer risk (approximately 0.5% per patient-year), symptom control strategies, and surveillance recommendations. 1, 3
• Provide both verbal and written information, including a lay summary of endoscopy findings in each report. 1
• Screen for cardiovascular risk factors, as cardiovascular deaths are more common than deaths from esophageal adenocarcinoma among patients with Barrett's esophagus. 1

Common Pitfalls to Avoid

• Do not rely on community pathology alone for dysplasia diagnosis—always obtain expert GI pathology confirmation. 4
• Do not perform ablation before EMR of visible lesions, as this prevents accurate staging. 4
• Do not assume antireflux surgery eliminates cancer risk—continue surveillance at the same intervals as medically treated patients. 1, 3
• Do not use chromoendoscopy or advanced imaging techniques for routine surveillance, though they may help guide biopsies in patients with known dysplasia or mucosal irregularities. 1