Diagnosis and Management of Barrett's Esophagus: An Updated ACG Guideline

Abstract

Barrett's esophagus (BE) is a common condition associated with chronic gastroesophageal reflux disease. BE is the only known precursor to esophageal adenocarcinoma, a highly lethal cancer with an increasing incidence over the last 5 decades. These revised guidelines implement Grading of Recommendations, Assessment, Development, and Evaluation methodology to propose recommendations for the definition and diagnosis of BE, screening for BE and esophageal adenocarcinoma, surveillance of patients with known BE, and the medical and endoscopic treatment of BE and its associated early neoplasia. Important changes since the previous iteration of this guideline include a broadening of acceptable screening modalities for BE to include nonendoscopic methods, liberalized intervals for surveillance of short-segment BE, and volume criteria for endoscopic therapy centers for BE. We recommend endoscopic eradication therapy for patients with BE and high-grade dysplasia and those with BE and low-grade dysplasia. We propose structured surveillance intervals for patients with dysplastic BE after successful ablation based on the baseline degree of dysplasia. We could not make recommendations regarding chemoprevention or use of biomarkers in routine practice due to insufficient data.

Impact of expert center endoscopic assessment of confirmed low grade dysplasia in Barrett’s esophagus diagnosed in community hospitals

“…It is well known that LGD is a challenging diagnosis and guidelines therefore recommend expert pathologist review for each LGD diagnosis 8 9 10 11 . The differentiation between reactive inflammatory changes and early dysplasia is complex.…”

“…Moreover, a subtle lesion may also have been missed during the second endoscopy, with additional delay and risk for progression. The Dutch and European BE guidelines recommend that patients with confirmed LGD are referred to an expert center for re-staging within 3 months, whereas US guidelines advise re-staging after 3–6 months with high definition and (optical) chromoendoscopy, not necessarily at an expert center 8 9 10 28 29 . Considering the high rates of worse histopathology found at the expert endoscopy, we would advocate for re-staging within 3–6 months upon referral in an expert center as advised by the Dutch and European guideline.…”

“…Regular surveillance endoscopies for patients with NDBE are performed in community hospitals. Surveillance endoscopies consist of imaging followed by random biopsies according to the Seattle protocol (i. e. 4-quadrant biopsies at every 2 cm) 10 , and targeted biopsies from visible lesions. These biopsy specimens are read by the community hospital pathologist.…”

“…In contrast, for confirmed LGD, the risk of malignant progression increased to 9 %–13 % per patient-year 6 7 . Therefore, current guidelines advise that a community diagnosis of LGD is reviewed, and if necessary revised, by an experienced pathologist 8 9 10 11 .…”

Performance status of targeted biopsy alone versus Sydney protocol by non-NBI expert gastroenterologist in gastric intestinal metaplasia diagnosis

“…However, this hypothesis should be confirmed by further study that includes more endoscopists. Nevertheless, a gastroenterology training curriculum should provide training in IEE for premalignant and early gastric cancer detection instead of implementing random biopsy for surveillance of many early gastrointestinal malignancies, such as GIM 5 21 and Barrett’s esophagus (BE) 22 23 . For instance, in 2016, a guideline from the American College of Gastroenterology (ACG) strongly suggested that at least eight biopsies be taken in patients with BE during EGD surveillance 22 .…”