Diagnosis and Management of Barrett's Esophagus

Publication Date: March 30, 2022
Last Updated: April 1, 2022

Diagnosis

We suggest that a diagnosis of BE require the finding of intestinal metaplasia (IM) in the tubular esophagus. (C, VL)
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We suggest that columnar mucosa of at least 1 cm in length be necessary for a diagnosis of BE, and that:
a. Patients with a normal-appearing Z line should not undergo routine endoscopic biopsies.
b. In the absence of any visible lesions, patients with a Z line demonstrating <1 cm of proximal displacement from the top of the gastric folds should not undergo routine endoscopic biopsies (C, L)
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We suggest at least 8 endoscopic biopsies be obtained in screening examinations with endoscopic findings consistent with possible BE, with the Seattle protocol followed for segments of longer than 4 cm. (C, L)
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We recommend that dysplasia of any grade detected on biopsies of BE be confirmed by a second pathologist with expertise in gastrointestinal (GI) pathology. (S, L)
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Screening

We suggest a single screening endoscopy for patients with chronic GERD symptoms and 3 or more additional risk factors for BE, including male sex, age >50 years, White race, tobacco smoking, obesity, and family history of BE or EAC in a first-degree relative. (C, VL)
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We suggest that a swallowable, nonendoscopic capsule sponge device combined with a biomarker is an acceptable alternative to endoscopy for screening for BE in those with chronic reflux symptoms and other risk factors. (C, VL)
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We suggest against repeat endoscopic screening in patients who have undergone an initial negative screening examination by endoscopy. (C, L)
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Surveillance

We recommend both white light endoscopy and chromoendoscopy in patients undergoing endoscopic surveillance of BE. (S, M)
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We recommend a structured biopsy protocol be applied to minimize detection bias in patients undergoing endoscopic surveillance of BE. (S, L)
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We suggest endoscopic surveillance be performed in patients with BE at intervals dictated by the degree of dysplasia noted on previous biopsies. (C, VL)
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Key Concepts - Surveillance

  • Consider cessation of endoscopic surveillance when a patient is no longer a candidate for EET.
  • Consider utilization of published quality indicators to benchmark your unit's performance against published standards.

Management

  • We could not make a recommendation on the use of wide-area transepithelial sampling with computer-assisted 3-dimensional (WATS-3D) analysis in patients undergoing endoscopic surveillance of BE.
  • We could not make a recommendation on the use of predictive tools (p53 staining and TissueCypher) in addition to standard histopathology in patients undergoing endoscopic surveillance of BE.
  • We could not make a recommendation on combination therapy with ASA and PPI in patients with BE to reduce the risk of progression to HGD/EAC.
We recommend that length of the NDBE segment be considered when assigning surveillance intervals such that longer segments of BE (≥3 cm) are surveyed on a 3-year interval and shorter segments of BE (<3 cm) are surveyed on a 5-year interval. (S, M)
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We suggest at least once-a-day PPI therapy in patients with BE without allergy or other contraindication to PPI use. (C, VL)
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We suggest against the use of antireflux surgery as an antineoplastic measure in patients with BE. (C, L)
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We recommend EET compared with esophagectomy in patients with BE with HGD or IMC. (S, M)
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We suggest endoscopic therapy in patients with BE with confirmed LGD to reduce the risk of progression to HGD/EAC, with endoscopic surveillance of confirmed LGD as an acceptable alternative. (C, M)
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We suggest initial ER of any visible lesions before the application of ablative therapy in patients with BE undergoing EET. (C, VL)
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We suggest that patients with BE undergoing EET be treated at high-volume centers. (C, VL)
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We recommend an endoscopic surveillance program in patients with BE who have completed successful EET. (S, M)
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Key Concepts - Management

  • Endoscopic cryotherapy may be considered as an alternative modality in patients unresponsive to RFA.
  • Patients with BE-related neoplasia embarking on EET should have a clear understanding of the risks and benefits associated with these therapies before initiation of therapy.
  • Endoscopists and centers performing EET should monitor their rates of CEIM, CED, and adverse events.

Recommendation Grading

Overview

Title

Diagnosis and Management of Barrett's Esophagus

Authoring Organization

Publication Month/Year

March 30, 2022

Last Updated Month/Year

February 12, 2024

Supplemental Implementation Tools

Document Type

Guideline

Country of Publication

US

Document Objectives

These guidelines are established to support clinical practice and suggest preferable approaches to a typical patient with a particular medical problem based on the currently available published literature. When exercising clinical judgment, particularly when treatments pose significant risks, health care providers should incorporate this guideline in addition to patient-specific medical comorbidities, health status, and preferences to arrive at a patient-centered care approach.

Inclusion Criteria

Male, Female, Adult, Older adult

Health Care Settings

Ambulatory, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Diagnosis, Management

Diseases/Conditions (MeSH)

D001471 - Barrett Esophagus

Keywords

Barrett's esophagus

Source Citation

Shaheen NJ, Falk GW, Iyer PG, Souza RF, Yadlapati RH, Sauer BG, Wani S. Diagnosis and Management of Barrett's Esophagus: An Updated ACG Guideline. Am J Gastroenterol. 2022 Apr 1;117(4):559-587. doi: 10.14309/ajg.0000000000001680. PMID: 35354777.