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