Diagnosis, Screening, and Surveillance
Diagnosis
Diagnose Barrett's esophagus with salmon-colored mucosa >1 cm proximal to the GEJ + intestinal metaplasia on biopsy.
Do not biopsy a normal Z-line or Z-line with <1 cm variability.
Describe extent of metaplasia using Prague C&M Criteria.
Characterize location of diaphragmatic hiatus, GEJ, and squamocolumnar junction.
If suspected BE, take >8 random biopsies; if short-segment (1-2 cm), take >4 biopsies per circumferential cm + 1 biopsy per cm in “tongues”.
Screening
Screen men with >5 years of weekly or more reflux symptoms (heartburn or regurgitation) + >2 risk factors (age >50, Caucasian, central obesity, current/former smoker, 1st degree family hx of BE/esophageal adenocarcinoma).
No routine screening recommended for women → lower risk of esophageal adenocarcinoma with chronic GER symptoms; consider screening if multiple risk factors.
No routine screening recommended for the general population.
Prior to screening, discuss possible implications of positive screen.
Consider unsedated transnasal endoscopy as an alternative to EGD for BE screening.
Surveillance
Discuss risks/benefits of surveillance prior to initiation.
Other imaging techniques not recommended for BE surveillance.
If prior dysplasia→ 4-quadrant bx at 1 cm intervals; if no prior dysplasia→ 4-quadrant bx at 2 cm intervals.
Sample mucosal abnormalities separately, with endoscopic mucosal resection (EMR) preferred; if BE with nodularity, refer to tertiary center for EMR.
Do not biopsy areas of esophagitis until healed with PPI therapy.
Diagnosis of BE with dysplasia must be reviewed by 2 pathologists (at least 1 GI-related).
If BE without dysplasia, no need to repeat EGD in 1 year for surveillance.
In cases of indefinite biopsy for dysplasia, repeat EGD after 3-6 mos of acid suppression, then yearly if indefinite for dysplasia confirmed.
If BE with low-grade dysplasia, endoscopic therapy preferred over yearly surveillance.
Therapy
Chemoprevention
Endoscopic
If nodular mucosa, perform EMR using histology to guide further therapy decisions.
Residual neoplasia should be assumed if neoplasia present at a deep margin post-EMR → surgical, systemic or additional endoscopic therapy should be considered.
No role for routine endoscopic ablative therapies for nondysplastic BE → low-risk of progression to esophageal adenocarcinoma.
If T1a esophageal adenocarcinoma, endoscopic ablative therapy preferred.
If T1b esophageal adenocarcinoma, multidisciplinary surgical oncology input recommended prior to endoscopic therapy; endoscopic therapy may be considered if superficial (sm1) disease without lymphovascular invasion.
If nodular BE, no benefit to staging with other modalities (i.e., EUS) prior to endoscopic mucosal resection.
If T1b esophageal adenocarcinoma, EUS may have a role in sampling regional lymph nodes.
Endoscopic Eradication Therapy
Management After Endoscopy
After complete eradication of intestinal metaplasia (CEIM), continue interval surveillance.
If high grade dysplasia/intramucosal carcinoma with CEIM, survey with EGD every 3 mos x 1 year, then every 6 mos x 1 year, then annually.
If low grade dysplasia with CEIM, survey with EGD every 6 mos x 1 year, then annually.
Inspect tubular esophagus + GEJ closely for mucosal abnormalities during surveillance EGD.
Surgical
Antireflux surgery not recommended for BE as antineoplastic therapy, but can be used as an adjunct to control reflux symptoms.
If EAC with submucosal invasion, esophagectomy + consideration of neoadjuvant therapy preferredAntireflux surgery not recommended for BE as antineoplastic therapy, but can be used as an adjunct to control reflux symptoms.
Literature
