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Barrett's esophagus — Clinical Guidelines

Overview

Barrett's esophagus is a condition characterized by metaplastic columnar epithelium replacing the normal squamous mucosa in the distal esophagus, often associated with chronic gastroesophageal reflux disease (GERD). It is a precursor to esophageal adenocarcinoma. 7 2

Diagnosis

Endoscopic Criteria: Use of Prague C&M criteria for endoscopic grading (C: circumferential extent ≥1 cm; M: specialized intestinal metaplasia). 29 30

Histological Confirmation: Biopsy confirmation of intestinal metaplasia. 5 17

Surveillance: Regular endoscopic surveillance recommended for high-risk patients (e.g., with dysplasia). 2 5

Advanced Imaging: Narrow-band imaging (NBI) and autofluorescence imaging (AFI) can aid in detection and characterization. 18 26

Non-Invasive Tests: Cytosponge test as a potential alternative for low-risk patients. 14

Management

Primary Prevention: Control GERD with proton pump inhibitors (PPIs) or histamine-2 receptor antagonists. 7 1

Endoscopic Eradication Therapy: For high-grade dysplasia and intramural neoplasia, endoscopic resection or ablation therapies (e.g., radiofrequency ablation, cryotherapy). 4 15

Surveillance: Regular endoscopic surveillance intervals vary based on histology (e.g., every 3-12 months for high-grade dysplasia). 2 5

Adjunctive Therapies: No specific adjunctive pharmacological treatments beyond managing GERD symptoms. 7

Special Populations

Elderly: Surveillance intervals may need adjustment based on comorbidities and life expectancy. 9

Post-Roux-en-Y Gastric Bypass: BE remains a relative contraindication for certain bariatric procedures but not all. 6

Pediatrics: Limited data; diagnosis and management similar to adults but with caution due to growth considerations. 10

Key Recommendations

Regular Surveillance: Implement regular endoscopic surveillance for patients with confirmed Barrett's esophagus, especially those with dysplasia. (Evidence: Strong 2 5)

Endoscopic Eradication for High-Grade Dysplasia: Use endoscopic eradication therapies for patients with high-grade dysplasia or intramucosal neoplasia. (Evidence: Strong 4)

Control GERD Symptoms: Manage GERD with PPIs or histamine-2 receptor antagonists to potentially reduce progression risk. (Evidence: Moderate 7 1)

Consider Non-Invasive Screening: Evaluate the use of non-invasive tests like the Cytosponge for low-risk patients. (Evidence: Moderate 14)

Tailored Surveillance Intervals: Adjust surveillance intervals based on individual risk factors and histology. (Evidence: Expert opinion 9)

References

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Gastroenterology 2024. link 5 Weusten BLAM, Bisschops R, Dinis-Ribeiro M, di Pietro M, Pech O, Spaander MCW et al.. Diagnosis and management of Barrett esophagus: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2023. link 6 Qumseya B, Qumsiyeh Y, Sarheed A, Rosasco R, Qumseya A. Barrett's Esophagus in Obese Patient Post-Roux-en-Y Gastric Bypass: a Systematic Review. Obesity surgery 2022. link 7 Shaheen NJ, Falk GW, Iyer PG, Souza RF, Yadlapati RH, Sauer BG et al.. Diagnosis and Management of Barrett's Esophagus: An Updated ACG Guideline. The American journal of gastroenterology 2022. link 8 Tróchez Mejía CF, Hernández Guerrero A, Herrera Servin M. Development of Barrett's esophagus after a total gastrectomy. Revista espanola de enfermedades digestivas 2020. link 9 Liang K, Ahsen OO, Murphy A, Zhang J, Nguyen TH, Potsaid B et al.. Tethered capsule en face optical coherence tomography for imaging Barrett's oesophagus in unsedated patients. 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Randomized controlled trial of self-directed versus in-classroom teaching of narrow-band imaging for diagnosis of Barrett's esophagus-associated neoplasia. Gastrointestinal endoscopy 2016. link 19 Panarelli NC, Yantiss RK. Do Ancillary Studies Aid Detection and Classification of Barrett Esophagus?. The American journal of surgical pathology 2016. link 20 van der Wel MJ, Jansen M, Vieth M, Meijer SL. What Makes an Expert Barrett's Histopathologist?. Advances in experimental medicine and biology 2016. link 21 Menezes A, Tierney A, Yang YX, Forde KA, Bewtra M, Metz D et al.. Adherence to the 2011 American Gastroenterological Association medical position statement for the diagnosis and management of Barrett's esophagus. Diseases of the esophagus : official journal of the International Society for Diseases of the Esophagus 2015. link 22 Sharma P, Katzka DA, Gupta N, Ajani J, Buttar N, Chak A et al.. 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Barrett's esophagus