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.

Barrett's%20esophagus Management

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 high-definition white light and preferably optical chromoendoscopy and do a 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 and endoscopically resected
  • Patients with documented Barrett’s esophagus should undergo surveillance endoscopy and the interval is determined by the grade of dysplasia
  • 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
  • Endoscopic surveillance should also be continued after a successful endoscopic therapy and complete removal of intestinal metaplasia to detect recurrence
    • Inspect the neosquamous mucosa and the gastric cardia (retroflexed) using high-definition white light and preferably optical chromoendoscopy and do 4-quadrant biopsies 

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, a follow-up esophagogastroduodenoscopy (EGD) with biopsy is performed within 1 year and repeated every 3-5 years if without change 
  • If with findings of dysplasia, follow appropriate treatment protocol

Low-Grade Dysplasia

  • A follow-up EGD with biopsy is performed within 3-6 months and repeated annually if without change 
    • If results are negative for 2 consecutive years, follow surveillance protocol for patients without dysplasia
    • An expert/experienced gastrointestinal pathologist should confirm the reading 
  • If with findings of dysplasia, follow appropriate treatment protocol 
  • After complete endoscopic and histologic eradication of intestinal metaplasia with endoscopic therapy, perform surveillance endoscopy with biopsies at 1 and 3 years

High-Grade Dysplasia

  • Finding of high-grade dysplasia requires a repeat thorough biopsy protocol ideally with therapeutic endoscopic and large-capacity biopsy forceps
    • An expert/experienced gastrointestinal pathologist should confirm the reading of high-grade dysplasia
  • Focal high-grade dysplasia (<5 crypts) may be followed with surveillance endoscopy every 3 months
  • After complete endoscopic and histologic eradication of intestinal metaplasia with endoscopic therapy, perform surveillance endoscopy with biopsies at 3, 6 and 12 months then yearly thereafter 
  • The routine use of endoscopic ultrasound to differentiate between mucosal and submucosal disease is not recommended in patients with high-grade dysplasia or early esophageal adenocarcinoma

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 the finding is indefinite for dysplasia, a 12-month interval for surveillance is recommended
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