Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

nondysplastic Barrett esophagus

1st line – proton-pump inhibitor plus surveillance

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ACUTE
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nondysplastic Barrett esophagus
1st line – 

proton-pump inhibitor plus surveillance

Acid suppression with a proton-pump inhibitor (PPI) is indicated to reduce acid exposure of the distal esophagus. 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. 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]

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]

Primary options

esomeprazole: 20 mg orally once daily initially, can increase to twice daily

OR

omeprazole: 20 mg orally once daily initially, can increase to twice daily

OR

pantoprazole: 40 mg orally once daily initially, can increase to twice daily

OR

rabeprazole: 20 mg orally once daily initially, can increase to twice daily

2nd line – antireflux surgery plus surveillance

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ACUTE
|
nondysplastic Barrett esophagus
2nd line – 

antireflux surgery plus surveillance

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]

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]

Whether or not PPIs should be continued after antireflux surgery is an open question. There are no data either to support or to refute this practice.

low-grade dysplasia

1st line – radiofrequency ablation with or without endoscopic mucosal resection or surveillance

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ACUTE
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low-grade dysplasia
1st line – 

radiofrequency ablation with or without endoscopic mucosal resection or surveillance

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 American Gastroenterological Association suggests endoscopic eradication therapy over surveillance in this patient group.[52]

Any visible lesions should be removed using endoscopic resection techniques and sent for histopathologic examination before performing radiofrequency ablation (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]

Consider – proton-pump inhibitor

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ACUTE
|
low-grade dysplasia
Consider – 

proton-pump inhibitor

Treatment recommended for SOME patients in selected patient group

These agents improve symptoms of reflux if present (although may not improve regurgitation and atypical symptoms e.g. laryngitis, respiratory symptoms).Whether this halts or retards progression of Barrett esophagus with low-grade dysplasia to carcinoma has not been demonstrated.

Primary options

esomeprazole: 20 mg orally once daily initially, can increase to twice daily

OR

omeprazole: 20 mg orally once daily initially, can increase to twice daily

OR

pantoprazole: 40 mg orally once daily initially, can increase to twice daily

OR

rabeprazole: 20 mg orally once daily initially, can increase to twice daily

high-grade dysplasia

1st line – radiofrequency ablation with or without endoscopic mucosal resection/endoscopic submucosal dissection

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ACUTE
|
high-grade dysplasia
1st line – 

radiofrequency ablation with or without endoscopic mucosal resection/endoscopic submucosal dissection

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.[7]​ 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 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]

Consider – proton-pump inhibitor

Back
ACUTE
|
high-grade dysplasia
Consider – 

proton-pump inhibitor

Treatment recommended for SOME patients in selected patient group

These agents improve reflux symptoms if present (although it may not improve regurgitation and atypical symptoms e.g. laryngitis, respiratory symptoms).

Whether this halts or retards progression of Barrett esophagus with high-grade dysplasia to carcinoma has not been demonstrated.

Primary options

esomeprazole: 20 mg orally once daily initially, can increase to twice daily

OR

omeprazole: 20 mg orally once daily initially, can increase to twice daily

OR

pantoprazole: 40 mg orally once daily initially, can increase to twice daily

OR

rabeprazole: 20 mg orally once daily initially, can increase to twice daily

2nd line – esophagectomy

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ACUTE
|
high-grade dysplasia
2nd line – 

esophagectomy

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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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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