Diagnosis and Management of Barrett’s Esophagus

1. BE should be diagnosed when there is extension of salmon-colored mucosa into the tubular esophagus extending ≥1 cm proximal to the gastroesophageal junction with biopsy confirmation of IM.

2. Endoscopic biopsy should not be performed in the presence of a normal Z line or a Z line with <1 cm of variability.

3. In the presence of BE, the endoscopist should describe the extent of metaplastic change including circumferential and maximal segment length using the Prague classification.

4. The location of the diaphragmatic hiatus, gastroesophageal junction, and squamocolumnar junction should be reported in the endoscopy report.

5. In patients with suspected BE, at least 8 random biopsies should be obtained to maximize the yield of IM on histology. In patients with short (1–2 cm) segments of suspected BE in whom 8 biopsies are unattainable, at least 4 biopsies per cm of circumferential BE, and one biopsy per cm in tongues of BE, should be taken.

6. In patients with suspected BE and lack of IM on histology, a repeat endoscopy should be considered in 1–2 years of time to rule out BE.

7. Screening for BE may be considered in men with chronic (>5 years) and/or frequent (weekly or more) symptoms of gastroesophageal refl ux (heartburn or acid regurgitation) and two or more risk factors for BE or EAC. These risk factors include: age >50 years, Caucasian race, presence of central obesity (waist circumference >102 cm or waist–hip ratio (WHR) >0.9), current or past history of smoking, and a confirmed family history of BE or EAC (in a first-degree relative).

8. Given the substantially lower risk of EAC in females with chronic GER symptoms (when compared with males), screening for BE in females is not recommended. However, screening could be considered in individual cases as determined by the presence of multiple risk factors for BE or EAC (age >50 years, Caucasian race, chronic and/or frequent GERD, central obesity: waist circumference >88 cm, WHR >0.8, current or past history of smoking, and a confirmed family history of BE or EAC (in a first-degree relative)).

9. Screening of the general population is not recommended.

10. Before screening is performed, the overall life expectancy of the patient should be considered, and subsequent implications, such as the need for periodic endoscopic surveillance and therapy, if BE with dysplasia is diagnosed, should be discussed with the patient.

11. Unsedated transnasal endoscopy (uTNE) can be considered as an alternative to conventional upper endoscopy for BE screening.

12. If initial endoscopic evaluation is negative for BE, repeating endoscopic evaluation for the presence of BE is not recommended. If endoscopy reveals esophagitis (Los Angeles Classification B, C, D), repeat endoscopic assessment after PPI therapy for 8–12 weeks is recommended to ensure healing of esophagitis and exclude the presence of underlying BE.

13. Patients should only undergo surveillance after adequate counseling regarding risks and benefi ts of surveillance.

14. Surveillance should be performed with high-definition/high-resolution white light endoscopy.

15. Routine use of advanced imaging techniques other than electronic chromoendoscopy is not recommended for endoscopic surveillance at this time.

16. Endoscopic surveillance should employ four-quadrant biopsies at 2 cm intervals in patients without dysplasia and 1 cm intervals in patients with prior dysplasia.

17. Mucosal abnormalities should be sampled separately, preferably with endoscopic mucosal resection. Inability to perform endoscopic mucosal resection in the setting of BE with nodularity should lead to consideration to referral to a tertiary care center.

18. Biopsies should not be obtained in mucosal areas with endoscopic evidence of erosive esophagitis until after intensification of antireflux therapy to induce mucosal healing.

19. For BE patients with dysplasia of any grade, review by two pathologists, at least one of whom has specialized expertise in GI pathology, is warranted because of interobserver variability in the interpretation of dysplasia.

20. Use of additional biomarkers for risk stratifi cation of patients with BE is currently not recommended.

21. For BE patients without dysplasia, endoscopic surveillance should take place at intervals of 3 to 5 years.

22. Patients diagnosed with BE on initial examination do not require a repeat endoscopy in 1 year for dysplasia surveillance.

23. For patients with indefinite for dysplasia, a repeat endoscopy after optimization of acid suppressive medications for 3–6 months should be performed. If the indefinite for dysplasia reading is confirmed on this examination, a surveillance interval of 12 months is recommended.

24. For patients with confirmed low-grade dysplasia and without life-limiting comorbidity, endoscopic therapy is considered as the preferred treatment modality, although endoscopic surveillance every 12 months is an acceptable alternative.

25. Patients with BE and confirmed high-grade dysplasia should be managed with endoscopic therapy unless they have life-limiting comorbidity.

39. Following successful endoscopic therapy and complete elimination of intestinal metaplasia (CEIM), endoscopic surveillance should be continued to detect recurrent IM and/or dysplasia.

40. Endoscopic surveillance following CEIM, for patients with HGD or IMC before ablation, is recommended every 3 months for the first year following CEIM, every 6 months in the second year, and annually thereafter.

41. In patients with LGD before ablation, endoscopic surveillance is recommended every 6 months in the first year following CEIM, and annually thereafter.

42. During endoscopic surveillance after CEIM, careful inspection of the tubular esophagus and gastroesophageal junction (in antegrade and retrograde views) should be performed with high-resolution white light imaging and narrow band imaging to detect mucosal abnormalities that may reflect recurrent IM and/or dysplasia.

43. Treatment of recurrent metaplasia and/or dysplasia should follow guidelines for the treatment of metaplasia/dysplasia in BE before ablation.

44. Following CEIM, the goal of medical antireflux therapy should be control of reflux as determined by absence of frequent reflux symptoms (more than once a week) and/or esophagitis on endoscopic examination.

45. Endoscopists who plan to practice endoscopic ablative procedures should additionally offer endoscopic mucosal resection.