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    Updated Diagnosis and Management of Barrett’s Esophagus (beta)

    Official guideline from the American College of Gastroenterology.

    Strength
    Strong recommendation
    Conditional recommendation
    Evidence
    Moderate quality evidence
    Low quality evidence
    Very low quality evidence

    Diagnosis, Screening, and Surveillance

    Diagnosis
    1. We recommend that dysplasia of any grade detected on biopsies of BE be confirmed by a second pathologist with expertise in GI pathology.
    2. 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.
    3. 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.
    4. We suggest that a diagnosis of BE require the finding of intestinal metaplasia in the tubular esophagus.
    Screening
    1. We suggest against repeat screening in patients who have undergone an initial negative screening examination by endoscopy.
    2. 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.
    3. We suggest that a swallowable, nonendoscopic capsule device combined with a biomarker is an acceptable alternative to endoscopy for screening for BE.
    Surveillance
    1. 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.
    2. We recommend both white light endoscopy and chromoendoscopy in patients undergoing endoscopic surveillance of BE.
    3. We recommend a structured biopsy protocol be applied to minimize detection bias in patients undergoing endoscopic surveillance of BE.
    4. We suggest endoscopic surveillance be performed in patients with BE at intervals dictated by the degree of dysplasia noted on previous biopsies.
    5. 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.
    6. 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
    1. We recommend endoscopic eradication therapy in patients with BE with HGD or IMC.
    2. We recommend an endoscopic surveillance program in patients with BE who have completed successful endoscopic eradication therapy.
    3. 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.
    4. We suggest initial endoscopic resection of any visible lesions before the application of ablative therapy in patients with BE undergoing endoscopic eradication therapy.
    5. We suggest that patients with BE undergoing endoscopic eradication therapy be treated in high-volume centers.
    Medical
    1. We suggest against the use of antireflux surgery as an antineoplastic measure in patients with BE.
    2. We suggest at least once-a-day PPI therapy in patients with BE without allergy or other contraindication to PPI use
    3. We could not make a recommendation on combination therapy with aspirin and proton pump inhibitor in patients with BE.
    What do the icons mean?  
    Research PaperShaheen NJ, Falk GW, Iyer PG, et al. Diagnosis and management of barrett’s esophagus: an updated acg guideline. Am J Gastroenterol. 2022;117(4):559-587.