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

Abstract

Barrett's esophagus (BE) is among the most common conditions encountered by the gastroenterologist. In this document, the American College of Gastroenterology updates its guidance for the best practices in caring for these patients. These guidelines continue to endorse screening of high-risk patients for BE; however, routine screening is limited to men with reflux symptoms and multiple other risk factors. Acknowledging recent data on the low risk of malignant progression in patients with nondysplastic BE, endoscopic surveillance intervals are attenuated in this population; patients with nondysplastic BE should undergo endoscopic surveillance no more frequently than every 3-5 years. Neither routine use of biomarker panels nor advanced endoscopic imaging techniques (beyond high-definition endoscopy) is recommended at this time. Endoscopic ablative therapy is recommended for patients with BE and high-grade dysplasia, as well as T1a esophageal adenocarcinoma. 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. Given the relatively common recurrence of BE after ablation, we suggest postablation endoscopic surveillance intervals. Although many of the recommendations provided are based on weak evidence or expert opinion, this document provides a pragmatic framework for the care of the patient with BE.

Figure 1.

Illustration of Prague Classifi cation for Barrett’s esophagus (BE) where C indicates circumferential extent of metaplasia and M indicates maximal extent of metaplasia. Schema shows a C2M5 segment with identifi cation of the gastroesophageal junction (GEJ) below the squamocolumnar junction. Reprinted with permission ( 24 ).

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.

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.