Updated Diagnosis and Management of Barrett’s Esophagus
Official guideline from the American College of Gastroenterology.
Diagnosis, Screening, and Surveillance
Diagnosis
We recommend that dysplasia of any grade detected on biopsies of BE be confirmed by a second pathologist with expertise in GI pathology.
Strong recommendation
Low quality evidence
We suggest that columnar mucosa of at least 1 cm in length be necessary for a diagnosis of BE.
a. Patients with a normal-appearing Z line should not undergo routine endoscopic biopsies.
b. In the absence of any visible lesions, patients with a Z line demonstrating <1 cm of proximal displacement from the top of the gastric folds should not undergo routine endoscopic biopsies.
a. Patients with a normal-appearing Z line should not undergo routine endoscopic biopsies.
b. In the absence of any visible lesions, patients with a Z line demonstrating <1 cm of proximal displacement from the top of the gastric folds should not undergo routine endoscopic biopsies.
Conditional recommendation
Low quality evidence
We suggest at least 8 endoscopic biopsies be obtained in screening examinations with endoscopic findings consistent with possible BE, with the Seattle protocol followed for segments of longer than 4 cm.
Conditional recommendation
Low quality evidence
We suggest that a diagnosis of BE require the finding of intestinal metaplasia in the tubular esophagus.
Conditional recommendation
Very low quality evidence
Screening
We suggest against repeat screening in patients who have undergone an initial negative screening examination by endoscopy.
Conditional recommendation
Low quality evidence
We suggest a single screening endoscopy in patients with chronic GERD symptoms and 3 or more additional risk factors for BE, including male sex, age >50 yr, white race, tobacco smoking, obesity, and family history of BE or EAC in a first-degree relative.
Conditional recommendation
Very low quality evidence
We suggest that a swallowable, nonendoscopic capsule device combined with a biomarker is an acceptable alternative to endoscopy for screening for BE.
Conditional recommendation
Very low quality evidence
Surveillance
We recommend that length of BE segment be considered when assigning surveillance intervals with longer intervals reserved for those with BE segments of <3 cm.
Strong recommendation
Moderate quality evidence
We recommend both white light endoscopy and chromoendoscopy in patients undergoing endoscopic surveillance of BE.
Strong recommendation
Low quality evidence
We recommend a structured biopsy protocol be applied to minimize detection bias in patients undergoing endoscopic surveillance of BE.
Strong recommendation
Low quality evidence
We suggest endoscopic surveillance be performed in patients with BE at intervals dictated by the degree of dysplasia noted on previous biopsies.
Conditional recommendation
Very low quality evidence
We could not make a recommendation on the use of wide-area transepithelial sampling with computer-assisted 3-dimensional analysis in patients undergoing endoscopic surveillance of BE.
We could not make a recommendation on the use of predictive tools (p53 staining and TissueCypher) in addition to standard histopathology in patients undergoing endoscopic surveillance of BE.
Treatment
Endoscopic
We recommend endoscopic eradication therapy in patients with BE with HGD or IMC.
Strong recommendation
Moderate quality evidence
We recommend an endoscopic surveillance program in patients with BE who have completed successful endoscopic eradication therapy.
Strong recommendation
Moderate quality evidence
We suggest endoscopic eradication therapy in patients with BE with LGD to reduce the risk of progression to HGD or EAC vs close endoscopic surveillance.
Conditional recommendation
Moderate quality evidence
We suggest initial endoscopic resection of any visible lesions before the application of ablative therapy in patients with BE undergoing endoscopic eradication therapy.
Conditional recommendation
Very low quality evidence
We suggest that patients with BE undergoing endoscopic eradication therapy be treated in high-volume centers.
Conditional recommendation
Very low quality evidence
Medical
We suggest against the use of antireflux surgery as an antineoplastic measure in patients with BE.
Conditional recommendation
Low quality evidence
We suggest at least once-a-day PPI therapy in patients with BE without allergy or other contraindication to PPI use
Conditional recommendation
Very low quality evidence
We could not make a recommendation on combination therapy with aspirin and proton pump inhibitor in patients with BE.
What do the icons mean?
How strong is the ACG's recommendation?
Strong recommendation
Intervention's desirable effects clearly outweigh undesirable effects.Conditional recommendation
Uncertainty in tradeoffs between desirable & undesirable effects of intervention.Moderate quality evidence
Further research likely to impact confidence in estimate of effect.Low quality evidence
Further research expected to have important impact in confidence in estimate of effect.Very low quality evidence
Any estimate of effect is very uncertain.
