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    Diagnosis and Management of Barrett’s Esophagus (beta)

    Official guideline from the American College of Gastroenterology.

    Summary by Shawn Shah, MD & Adam Buckholz, MD
    Strength
    Strong recommendation
    Moderate recommendation
    Conditional recommendation
    Weak recommendation
    Evidence
    High quality evidence
    Moderate-high quality evidence
    Moderate quality evidence
    Low quality evidence
    Very low quality evidence

    Diagnosis, Screening, and Surveillance

    Diagnosis
    1. Diagnose Barrett's esophagus with salmon-colored mucosa >1 cm proximal to the GEJ + intestinal metaplasia on biopsy.
    2. Do not biopsy a normal Z-line or Z-line with <1 cm variability.
    3. Describe extent of metaplasia using Prague C&M Criteria.
    4. Characterize location of diaphragmatic hiatus, GEJ, and squamocolumnar junction.
    5. 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”.
    6. If diagnosis not made despite visual BE appearance, consider repeat EGD in 1-2 years.
    Screening
    1. 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).
    2. No routine screening recommended for women → lower risk of esophageal adenocarcinoma with chronic GER symptoms; consider screening if multiple risk factors.
    3. No routine screening recommended for the general population.
    4. Prior to screening, discuss possible implications of positive screen.
    5. Consider unsedated transnasal endoscopy as an alternative to EGD for BE screening.
    6. If negative screening test, no need to repeat; if esophagitis (LA Class B, C, D), perform repeat EGD in 8-12 weeks after PPI therapy to evaluate for BE.
    Surveillance
    1. Discuss risks/benefits of surveillance prior to initiation.
    2. Survey with HD/high-resolution white light endoscopy.
    3. Other imaging techniques not recommended for BE surveillance.
    4. If prior dysplasia→ 4-quadrant bx at 1 cm intervals; if no prior dysplasia→ 4-quadrant bx at 2 cm intervals.
    5. Sample mucosal abnormalities separately, with endoscopic mucosal resection (EMR) preferred; if BE with nodularity, refer to tertiary center for EMR.
    6. Do not biopsy areas of esophagitis until healed with PPI therapy.
    7. Diagnosis of BE with dysplasia must be reviewed by 2 pathologists (at least 1 GI-related).
    8. Biomarker use for risk stratification is not recommended.
    9. If BE without dysplasia, survey every 3-5 years.
    10. If BE without dysplasia, no need to repeat EGD in 1 year for surveillance.
    11. In cases of indefinite biopsy for dysplasia, repeat EGD after 3-6 mos of acid suppression, then yearly if indefinite for dysplasia confirmed.
    12. If BE with low-grade dysplasia, endoscopic therapy preferred over yearly surveillance.
    13. If BE with high-grade dysplasia, proceed with endoscopic therapy unless life-threatening illness.

    Therapy

    Chemoprevention
    1. Use daily PPI for all patients with BE; can use BID PPI if uncontrolled reflux symptoms.
    2. Antineoplastic and chemopreventive strategies including ASA/NSAIDs not recommended.
    Endoscopic
    1. If nodular mucosa, perform EMR using histology to guide further therapy decisions.
    2. Residual neoplasia should be assumed if neoplasia present at a deep margin post-EMR → surgical, systemic or additional endoscopic therapy should be considered.
    3. No role for routine endoscopic ablative therapies for nondysplastic BE → low-risk of progression to esophageal adenocarcinoma.
    4. If T1a esophageal adenocarcinoma, endoscopic ablative therapy preferred.
    5. 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.
    6. If nodular BE, no benefit to staging with other modalities (i.e., EUS) prior to endoscopic mucosal resection.
    7. If T1b esophageal adenocarcinoma, EUS may have a role in sampling regional lymph nodes.
    8. If nonnodular dysplastic BE, radiofrequency ablation preferred.
    Endoscopic Eradication Therapy
    1. Endoscopists who plan to practice ablative procedures should offer EMR.
    Management After Endoscopy
    1. After complete eradication of intestinal metaplasia (CEIM), continue interval surveillance.
    2. 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.
    3. If low grade dysplasia with CEIM, survey with EGD every 6 mos x 1 year, then annually.
    4. Inspect tubular esophagus + GEJ closely for mucosal abnormalities during surveillance EGD.
    5. If recurrence of BE, treat the same as if primary disease.
    6. After CEIM, use medical therapy to control reflux symptoms or esophagitis.
    Surgical
    1. Antireflux surgery not recommended for BE as antineoplastic therapy, but can be used as an adjunct to control reflux symptoms.
    2. 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.
    3. Consider surgical and/or multimodality therapies for patients with T1a/T1b superficial EAC, poor differentiation, lymphovascular invasion, or incomplete EMR.
    What do the icons mean?  
    Research PaperShaheen NJ, Falk GW, Iyer PG, Gerson LB. ACG Clinical Guideline: Diagnosis and Management of Barrett's Esophagus. Am J Gastroenterol. 2016;111(1):30-50.