Barrett's%20esophagus Management

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