barrett's%20esophagus
BARRETT'S ESOPHAGUS
Barrett's esophagus is defined as the endoscopic finding in the distal esophagus of proximal-appearing columnar-lined esophagus of at least 1-cm length that is confirmed by histology.
It is considered a premalignant metaplastic condition that usually involves the distal esophagus.
It is postulated that exposure of the esophageal epithelium to acid damages the lining resulting in chronic esophagitis and its healing involves metaplastic process.

Monitoring

Principles of Endoscopic Surveillance

  • Surveillance aims to detect dysplasia and early cancer
    • Dysplasia is described as cellular and architectural changes and represents the final step of neoplasia
  • Endoscopy with random sampling for dysplasia remains the clinical standard for managing Barrett’s esophagus
    • Perform endoscopy with white light and do 4-quadrant biopsy every 2 cm for surveillance and every 1 cm in patients in whom dysplasia is documented or suspected
    • Visibly raised or depressed lesions should be biopsied
  • Patients with documented Barrett’s esophagus should undergo surveillance endoscopy and the interval is determined by the grade of dysplasia
    • Endoscopic surveillance should also be continued after a successful endoscopic therapy and complete removal of intestinal metaplasia to detect recurrence
  • Dysplasia is considered as the best current indicator of cancer risk
    • A meta-analysis of multiple studies showed a 6-7% risk of progression from high-grade dysplasia to cancer per patient per year
    • Biomarkers, though promising, cannot be used for confirmation of the diagnosis of Barrett’s dysplasia or as a way of stratifying risk for progression in patients with Barrett’s esophagus at the current time

Surveillance Recommendations

  • Prior to endoscopy, patients should be treated with empiric therapy since it facilitates identification of Barrett’s esophagus by reducing any tissue inflammation
  • Routine surveillance with other advanced imaging methods except for electronic chromoendoscopy is not recommended in patients with Barrett’s esophagus at the current time

No Dysplasia

  • In patients without dysplasia, as confirmed by 2 esophagogastroduodenoscopies with biopsies performed within 1 year, a follow-up endoscopy may be done every 3-5 years

Indefinite for Dysplasia

  • Biopsy changes that cannot be described as reactive or neoplastic
  • Endoscopy is repeated after acid suppressive therapy for 3-6 months
    • If indefinite for dysplasia is the reading, a 12-month interval for surveillance is recommended

Low-Grade Dysplasia

  • Low-grade dysplasia, as confirmed by highest grade on repeat endoscopy and another esophagogastroduodenoscopy with biopsies within 6 months, may have follow-up endoscopy yearly
    • An expert pathologist should confirm the reading
  • If endoscopy shows a focal lesion, resection of the lesion may be performed; if focal lesions are absent, may consider radiofrequency ablation

High-Grade Dysplasia

  • Finding of high-grade dysplasia requires a repeat thorough biopsy protocol ideally with therapeutic endoscopic and large-capacity biopsy forceps
    • A recognized pathologist should confirm the reading of high-grade dysplasia
  • Focal high-grade dysplasia (<5 crypts), may be followed with surveillance endoscopy every 3 months
  • As synchronous cancer can occur with high-grade dysplasia, intervention, eg endoscopic resection, instead of continued surveillance may be done  
    • Endoscopic resection may be performed if the lesion can be localized endoscopically
  • For patients with confirmed multifocal high-grade dysplasia, intervention may be considered (eg endoscopic mucosal resection, radiofrequency ablation or ablation using cryotherapy, photodynamic therapy, esophagectomy)
    • Any raised or suspicious lesions should undergo diagnostic endoscopic resection in patients with dysplastic Barrett’s esophagus or early esophageal adenocarcinoma
    • Complete eradication of the Barrett’s esophagus segment along with other dysplastic lesions is the goal of endoscopic treatment in patients with Barrett’s esophagus-associated neoplasia
    • Radiofrequency ablation is the preferred endoscopic ablative therapy at this time for patients with dysplastic Barrett’s esophagus non-nodular disease; undetected synchronous lesions can be treated and development of metachronous lesions can be prevented
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