Approach

The goal of treatment of Barrett esophagus is to reduce reflux of gastric acid into the esophagus and eliminate the Barrett epithelium.

Nondysplastic Barrett esophagus

  • Treatment with proton-pump inhibitors (PPIs) and surveillance: use of PPIs is associated with a decreased risk of progression to high grade Barrett esophagus or esophageal carcinoma.[7] Although most drugs are designed to be administered once daily, treatment may be increased to twice daily in order to avoid periods when the hydrogen ion concentration can reduce the intraluminal pH to below 4. However, the American College of Gastroenterology guidelines state that increasing the frequency to twice daily dosing should be balanced with the increased risk of potential harm with long-term therapy.[7] One phase 3 open-label trial reported a small but significant reduction in all-cause mortality in patients with Barrett esophagus treated with high-dose esomeprazole, compared with low-dose esomeprazole, after 8.9 years of treatment.[51]

  • Antireflux surgery: although antireflux surgery, such as Nissen fundoplication may be effective at reducing gastroesophageal reflux symptoms, guidelines recommend against the use of antireflux surgery to reduce the risk of progression of Barrett esophagus to adenocarcinoma.[7][33]​ These recommendations are based on the risks and potential complications associated with the minimally invasive surgery, as well as the lack of sufficient evidence documenting a lower risk of progression to neoplasia in this patient group. Antireflux surgery may be considered for treatment of reflux symptoms in people with Barrett esophagus who have a poor or incomplete symptomatic response to PPIs.[1]

The American Gastroenterological Association (AGA) suggests not using endoscopic eradication therapy on a routine basis in patients with nondysplastic Barrett esophagus.[52]

Surveillance is recommended every 5 years for nondysplastic Barrett esophagus <3 cm long, and every 3 years for nondysplastic Barrett esophagus ≥3 cm long.[7]

Guidelines recommend against routine use of endoscopic therapies such as radiofrequency ablation (RFA) for the eradication of nondysplastic Barrett esophagus, because of the low risk of progression to dysplasia and adenocarcinoma.[1][7][32]​​

Barrett esophagus with low-grade dysplasia

Dysplasia is an important predictor of cancer risk in Barrett esophagus but there is considerable interobserver variability on its interpretation. The diagnosis of any degree of dysplasia (or indefinite for dysplasia) requires confirmation by an experienced gastrointestinal pathologist.

Patients with Barrett esophagus with low grade dysplasia may be managed with surveillance or endoscopic eradication therapy.[7][32]​​[53]​ Discuss the risks and benefits of surveillance versus endoscopic eradication therapy with patients who have low grade dysplasia.[7]​ The AGA suggests endoscopic eradication therapy over surveillance in this patient group.[52]

Any visible lesions should be removed used endoscopic resection techniques and sent for histopathologic examination before performing RFA.[7][32]​​​ RFA is the preferred ablative technique.[32][50]​[52]​​​ The aim of RFA is complete eradication of intestinal metaplasia.[7]​ The National Institute for Health and Care Excellence (NICE) in the UK recommends offering RFA to patients with low-grade esophageal dysplasia diagnosed from biopsies taken at two separate endoscopies. Two gastrointestinal pathologists should confirm the histologic diagnosis.[33]

One randomized trial demonstrated that ablation of low-grade dysplasia reduces the incidence of progression to adenocarcinoma.[54] Adverse events associated with RFA include esophageal stricture formation and post procedure pain. Bleeding and esophageal perforation are rare.[55]

Patients require regular surveillance after treatment; surveillance intervals are dictated by pretreatment histology.[7]

Barrett esophagus with high-grade dysplasia

The finding of high-grade dysplasia is associated with a 20% to 40% risk of harboring adenocarcinoma.[1][56]​ If high-grade dysplasia is confirmed, endoscopic eradication therapy is recommended over surveillance.[7][52] NICE in the UK recommends endoscopic resection of visible esophageal lesions for the first-line treatment of patients with high-grade dysplasia.[33]

Visible lesions should be resected and all remaining Barrett's epithelium eradicated.[1][7]​​[32]​​

Endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) should be used to resect visible lesions.[1][7]​​[32]​​[52]​ Resected lesions should undergo histologic analysis. EMR is an effective treatment for nodular high-grade dysplasia as it achieves complete resection of the dysplastic area with negative margins.[57] ESD is a highly effective technique that provides specimens with wider lateral margins and increased depth, but it is only available at specialized centers.

NICE in the UK recommends offering endoscopic ablation to remove any residual Barrett esophagus in patients with high-grade dysplasia after treatment with endoscopic resection.[33] After EMR or ESD, RFA is the preferred ablative technique to eradicate remaining Barrett epithelium.[7][52]​ The efficacy and safety of RFA is supported by robust data, including results from one multicenter, sham-controlled, randomized clinical trial demonstrating complete eradication of the dysplastic epithelium in 81% of patients treated with this technique.[58] Adverse events of RFA with or without EMR are: esophageal stricture (5.6%), bleeding (1%) and esophageal perforation (0.6%).[55]

Patients require regular surveillance after treatment; surveillance intervals are dictated by pretreatment histology.[7]

Esophagectomy is a definitive treatment option, which enables identification of any occult malignancy.[59] However, this intervention is associated with significant procedure-related mortality and long-term morbidity.[60]

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