Screening
Asymptomatic patients
Screening of the general population is not recommended by current guidelines.[7][32] Barrett's oesophagus is typically discovered incidentally in asymptomatic patients undergoing endoscopic evaluation of the upper gastrointestinal tract for other indications.
Patients with GORD
The American College of Gastroenterology and the European Society of Gastrointestinal Endoscopy recommend using a risk-based selection process to identify individuals with chronic GORD who may benefit from screening and surveillance programmes for Barrett's oesophagus.[7][32] The guidelines suggest considering endoscopic screening for Barrett's oesophagus in patients with chronic GORD symptoms (>5 years) and ≥3 risk factors associated with oesophageal adenocarcinoma: age >50 years, male sex, white, obesity, current or past history of smoking, and a confirmed family history of Barrett's oesophagus or oesophageal adenocarcinoma in a first-degree relative.
Surveillance of Barrett's oesophagus
The goal of surveillance programmes for dysplasia or cancer is to improve survival with the early detection of lesions. Evidence supporting improved outcomes in individuals with Barrett's oesophagus undergoing surveillance programmes was previously conflicting. However, population-based studies have demonstrated improved survival in those with Barrett's oesophagus enrolled in surveillance programmes, by diagnosing oesophageal adenocarcinoma earlier.[46]
Prior to initiating a surveillance programme, a detailed discussion of potential benefits and risks for individual patients, as well as limitations of currently available means of surveillance, must take place. Individual preferences with regards to repeated endoscopic evaluations, endoscopic therapies, surgery, chemotherapy, and radiotherapy must be accounted for.
High-resolution/high-definition white light endoscopy with Seattle protocol-based endoscopic biopsies are currently standard of care for surveillance of Barrett’s oesophagus.[7][32][33] Seattle protocol involves obtaining biopsies of the suspected Barrett's oesophagus segment in four quadrants, every 1-2 centimeters.
The National Institute for Health and Care Excellence (NICE) in the UK recommends offering high-resolution white light endoscopic surveillance with Seattle protocol every 2 to 3 years to patients with long-segment Barrett's oesophagus and every 3 to 5 years to patients with short-segment Barrett's oesophagus with intestinal metaplasia.[33] Endoscopic surveillance should not be offered to patients with short-segment Barrett's oesophagus without intestinal metaplasia, provided the diagnosis has been confirmed at two endoscopies.[33]
American College of Gastroenterology guidelines now recommend the use of both whitelight endoscopy and digital chromoendoscopy for the endoscopic surveillance of Barrett's oesophagus.[7] Digital chromoendoscopy uses optical filters to narrow the bandwidth from white light to blue light. Post-processing software provides a similar effect and is readily available on newer generation endoscopes.
Results from individual trials of digital chromoendoscopy results in increased detection of dysplasia or neoplasia in individuals with Barrett’s oesophagus have been mixed.[47] However, data from one meta-analysis suggest increased detection of dysplasia or neoplasia when digital chromoendoscopy is used.[39]
An alternative form of chromoendoscopy is acetic acid chromoendoscopy using acetic acid as a vital dye.[7] Although advanced imaging techniques, such as confocalendomicroscopy or volumetric laser endomicroscopy may prove to be useful in selected patients, their routine use is not recommended.
The interval between surveillance endoscopies is dictated by the degree of dysplasia noted on previous biopsies and the length of the Barrett's oesophagus segment.[7]
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