Screening
Asymptomatic patients
Screening of the general population is not recommended by current guidelines.[7][32] Barrett esophagus is typically discovered incidentally in asymptomatic patients undergoing endoscopic evaluation of the upper gastrointestinal tract for other indications.
Patients with GERD
The American College of Gastroenterology and the European Society of Gastrointestinal Endoscopy recommend using a risk-based selection process to identify individuals with chronic GERD who may benefit from screening and surveillance programs for Barrett esophagus.[7][32] The guidelines suggest considering endoscopic screening for Barrett esophagus in patients with chronic GERD symptoms (>5 years) and ≥3 risk factors associated with esophageal adenocarcinoma: age >50 years, male sex, white, obesity, current or past history of smoking, and a confirmed family history of Barrett esophagus or esophageal adenocarcinoma in a first-degree relative.
Surveillance of Barrett esophagus
The goal of surveillance programs for dysplasia or cancer is to improve survival with the early detection of lesions. Evidence supporting improved outcomes in individuals with Barrett esophagus undergoing surveillance programs was previously conflicting. However, population-based studies have demonstrated improved survival in those with Barrett esophagus enrolled in surveillance programs, by diagnosing esophageal adenocarcinoma earlier.[46]
Prior to initiating a surveillance program, 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 radiation therapy 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 esophagus.[7][32][33] Seattle protocol involves obtaining biopsies of the suspected Barrett esophagus 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 esophagus and every 3 to 5 years to patients with short-segment Barrett esophagus with intestinal metaplasia.[33] Endoscopic surveillance should not be offered to patients with short-segment Barrett esophagus 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 esophagus.[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 esophagus 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 esophagus segment.[7]
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