From the Guidelines
For Barrett's esophagus follow-up, endoscopic surveillance should be performed based on the degree of dysplasia present, with the most recent guidance from the National Institute for Health and Care Excellence (NICE) in 2024 1 emphasizing the need for personalized management strategies.
Key Considerations
- Patients with non-dysplastic Barrett's esophagus should undergo endoscopy every 3-5 years, as recommended by previous guidelines 1.
- Those with low-grade dysplasia should have endoscopy every 6-12 months for the first year, then annually until two consecutive endoscopies show no dysplasia, in line with expert review from the American Gastroenterological Association in 2016 1.
- Patients with high-grade dysplasia require more aggressive management with endoscopic eradication therapy and follow-up every 3 months for the first year.
Surveillance and Management
- All patients should be on acid suppression therapy, typically with a proton pump inhibitor (PPI) like omeprazole 20-40mg daily or equivalent, to control acid reflux and prevent progression to esophageal adenocarcinoma.
- Lifestyle modifications are also important, including weight loss if overweight, avoiding meals within 3 hours of bedtime, elevating the head of the bed, and avoiding trigger foods, alcohol, and smoking.
- The British Society of Gastroenterology guidelines in 2014 1 provide a surveillance flow chart for dysplastic Barrett's oesophagus, which can be used to guide management decisions.
Recent Guidance
- The NICE guidance in 2024 1 highlights the need for future research on the diagnostic accuracy of different endoscopic surveillance techniques, the usefulness of clinical and molecular biomarkers, and the effectiveness of endoscopic resection and ablation for adults with Barrett's oesophagus.
- However, based on the current evidence, endoscopic surveillance and acid suppression therapy remain the cornerstone of management for patients with Barrett's esophagus, with the goal of preventing progression to esophageal adenocarcinoma and detecting any cancerous changes early.
From the Research
Follow-up Protocols for Barrett's Esophagus
- The American College of Gastroenterology recommends surveillance endoscopy at intervals of every 2 to 3 years for patients with no dysplasia 2.
- For patients with low-grade dysplasia, surveillance endoscopy every 6 months for the first year is recommended, followed by yearly endoscopy if the dysplasia has not progressed in severity 2.
- In cases of high-grade dysplasia, two alternatives are proposed: intensive endoscopic surveillance until intramucosal cancer is detected at an interval of every 3-6 months, or esophageal resection 2.
- A systematic review suggests that endoscopic surveillance protocols should be based on the presence and degree of dysplasia, as well as the length of the follow-up affected by Barrett's esophagus 3.
Surveillance Intervals
- For patients with Barrett's esophagus without dysplasia and 1-3 cm of extension, esophagogastroduodenoscopy (EGD) every 5 years is recommended 3.
- For patients with Barrett's esophagus without dysplasia and >3-10 cm of extension, EGD every 3 years is recommended 3.
- For patients with low-grade dysplasia, EGD every 6-12 months is recommended 3.
- After ablative endoscopic therapy in cases of high-grade dysplasia, EGD every 3 months is recommended 3.
Effectiveness of Surveillance
- Endoscopic surveillance in an expert Barrett's esophagus center leads to a high neoplastic progression rate and a low rate of disease-specific mortality 4.
- A multicentre randomised trial found that radiofrequency ablation modestly reduced the prevalence of low-grade dysplasia and progression risk at 3 years compared to surveillance 5.
- The efficacy of endoscopic surveillance for Barrett's esophagus is likely to remain unclear for a long time due to the low incidence of adenocarcinoma and the lack of understanding of the natural history of dysplasia 2.