ACG Clinical Guideline: Diagnosis and Management of Barrett's Esophagus

TLDR: Endoscopic ablative therapy is recommended for patients with BE and high-grade dysplasia, as well as T1a esophageal adenocarcinoma, and endoscopic surveillance intervals are attenuated, based on recent level 1 evidence.

About: This article is published in The American Journal of Gastroenterology.The article was published on 2016-01-01 and is currently open access. It has received 1222 citations till now. The article focuses on the topics: Barrett's esophagus & Population.

Figures

Table 2 . Risk factors for BE (estimates drawn from meta-analyses where available)

Table 3 . Cancer risk based on degree of dysplasia

Figure 3 . Management of nodular Barrett’s esophagus (BE). *Little data exist on the clinical course of patients with low-grade dysplasia (LGD) managed by endoscopic surveillance following endoscopic mucosal resection (EMR), although this is an alternative treatment strategy. Endoscopic submucosal dissection is an alternative to EMR. Favorable histology consists of no lymphatic or vascular invasion and moderate- to well-differentiated disease. EAC, esophageal adenocarcinoma.

Table 1 . Recommendation statements

Table 1 . Recommendation statements

Figure 2 . Management of nonnodular Barrett’s esophagus (BE). *Although endoscopic eradication therapy is associated with a decreased rate of progression, surveillance upper endoscopy at 1-year intervals is an acceptable alternative. The above schema assumes that the T1a esophageal adenocarcinoma (EAC) displays favorable characteristics for endoscopic therapy, including well-differentiated histology and lack of lymphovascular invasion. EGD, esophagogastroduodenoscopy; HGD, high-grade dysplasia; LGD, low-grade dysplasia; PPI, proton pump inhibitor.

Frequently asked questions

Q1. What are the risk factors associated with the development of BE?

Risk factors associated with the development of BE include long-standing GERD, male gender, central obesity ( 3 ), and age over 50 years ( 4,5 ). 

Q2. What is the way to treat BE?

Based on recent level 1 evidence, endoscopic ablative therapy is also recommended for patients with BE and low-grade dysplasia, although endoscopic surveillance continues to be an acceptable alternative. 

Q3. How many biopsies should be obtained in patients with BE?

In patients with short (1–2 cm) segments of suspected BE in whom 8 biopsies may be unobtainable, at least 4 biopsies per cm of circumferential BE, and one biopsy per cm in tongues of BE, should be obtained (conditional recommendation, low level of evidence). 

Q4. What is the goal of a screening and surveillance program for BE?

Th e goal of a screening and surveillance program for BE is to identify individuals at risk for progression to esophageal adenocarcinoma (EAC), a malignancy that has been increasing in incidence since the 1970s ( 6,7 ). 

Q5. How long should a repeat endoscopy be considered?

In patients with suspected BE and lack of IM on histology, a repeat endoscopy should be considered in 1–2 years of time to rule out BE (conditional recommendation, very low level of evidence). 

Q6. What is the way to diagnose BE?

BE should be diagnosed when there is extension of salmon-colored mucosa into the tubular esophagus extending ≥1 cm proximal to the gastroesophageal junction (GEJ) with biopsy confi rmation of IM (strong recommendation, low level of evidence). 

Q7. What is the definition of a BE segment?

Th erefore, in situations where BE is suspected, the authors recommend acquiring 4 biopsies every 2 cm of segment length, or a total of at least 8 biopsies if the segment is <2 cm, at the initial exam. 

Q8. What is the definition of a diaphragmatic hiatus?

Th e diaphragmatic hiatus is identifi ed as an indentation of the gastric folds that is apparent during upper endoscopy with inspiration. 

Q9. What is the definition of a segment of BE?

Any segment of BE measuring >3 cm has been classifi ed as long-segment BE, with segments <3 cm classifi ed as short-segment BE ( 23 ). 

Q10. What is the risk of Barrett’s esophagus?

Th e diagnosis of GERD is associated with a 10–15% risk of Barrett’s esophagus (BE), a change of the normal squamous epithelium of the distal esophagus to a columnar-lined intestinal metaplasia (IM). 

Q11. What should be reported in the endoscopy report?

Th e location of the diaphragmatic hiatus, GEJ, and squamocolumnar junction should be reported in the endoscopy report (conditional recommendation, low level of evidence). 

Q12. What is the way to determine whether a patient has a BE?

In the presence of BE, the endoscopist should describe the extent of metaplastic change including circumferential and maximal segment length using the Prague classifi cation (conditional recommendation, low level of evidence).