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

Abstract

Recent population studies suggest that gastroesophageal refl ux disease (GERD) is increasing in prevalence, both in the United States and worldwide ( 1,2 ). 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). Risk factors associated with the development of BE include long-standing GERD, male gender, central obesity ( 3 ), and age over 50 years ( 4,5 ). 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 ).Th e purpose of this guideline is to review the defi nition and epidemiology of BE, available screening modalities for BE detection, rationale and methods for surveillance, and available treatment modalities including medical, endoscopic, and surgical techniques. In order to evaluate the level of evidence and strength of recommendations, we used the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system ( 8 ). Th e level of evidence ranged from "high" (implying that further research was unlikely to change the authors' confi dence in the estimate of the eff ect) to "moderate" (further research would be likely to have an impact on the confi dence in the estimate of eff ect) to "low" (further research would be expected to have an important impact on the confi dence in the estimate of the eff ect and would be likely to change the estimate) or "very low" (any estimate of eff ect is very uncertain). Th e strength of a recommendation was graded as "strong" when the desirable eff ects of an intervention clearly outweighed the undesirable eff ects and as "conditional" when there was uncertainty about the tradeoff s. We used meta-analyses or systematic reviews when available, followed by clinical trials and cohort and case-control studies. In order to determine the level 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 refl ux 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-defi nition 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 ...

Cost–effectiveness analysis of endoscopic eradication therapy for treatment of high-grade dysplasia in Barrett’s esophagus

“…In 2013, the BSG [3] endorsed the use of minimally invasive endoscopic treatment for early Barrett's neoplasia, together with combined endoscopic resection for lesions, followed by ablation with radio frequency. The American Gastroenterological Association and American College of Gastroenterology also support this approach to patients with BE-related neoplasia over surveillance or surgery with esophagectomy [17,18].…”

Risk stratifying the screening of Barrett's esophagus: An Asian perspective

“…The literature highlights the importance of screening at risk patients in order to better survey and ultimately treat Barrett's associated dysplasia and cancer 2. This is in view of the fact that long‐term survival of patients with EAC is bleak 8…”

“…Analysis of demographics and symptoms was performed in relation to the gold standard of histology 2, 3…”

“…Despite the low risk of progression to EAC per annum, estimated currently at 0.12%, the prognosis of EAC is poor, with an estimated 5‐year survival of approximately 10–15% 1, 2…”

“…Given the generally low prevalence of BE, endoscopic screening of the general population cannot be advocated for, as recommended by the current guidelines in the United Kingdom and United States 2, 3. Current Western guidelines have proposed targeting endoscopic screening for populations at risk of BE.…”