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Barrett's esophagus

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Updated 2024 AGA guidelines for endoscopic eradication therapy in Barrett's esophagus.

Background

Overview

Definition
BE is a pre-neoplastic condition characterized by intestinal metaplasia of the esophageal squamous mucosa.
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Pathophysiology
In patients with BE, cellular damage to the esophageal mucosa is caused by chronic acid-induced mucosal injury associated with GERD.
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Epidemiology
In the US, the prevalence of BE is estimated at 5,600 persons per 100,000 population.
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Disease course
Chronic inflammation leads to activation of oncogenes and silencing of tumor suppressor genes, increasing the risk of esophageal adenocarcinoma and esophageal SCC.
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Prognosis and risk of recurrence
The rate of progression of high-grade dysplasia in patients with BE is approximately 6% per year.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of Barrett's esophagus are prepared by our editorial team based on guidelines from the American Gastroenterological Association (AGA 2024,2022,2017), the European Society of Gastrointestinal Endoscopy (ESGE 2023), the United European Gastroenterology (UEG/ESPEN 2023), the American College of Gastroenterology (ACG 2022,2016), the American Society for Gastrointestinal Endoscopy (ASGE 2019,2018), and the British ...
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Screening and diagnosis

Indications for screening, general population: as per ESGE 2023 guidelines, do not obtain screening for BE in an unselected population.
D
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  • Indications for screening (high-risk patients)

  • Indications for screening (before bariatric surgery)

  • Technical considerations for screening

  • Diagnostic criteria

Diagnostic investigations

Reflux monitoring
As per ACG 2022 guidelines:
Do not obtain reflux monitoring off therapy solely as a diagnostic test for GERD in patients with long-segment BE.
D
Consider obtaining esophageal pH monitoring (Bravo, catheter-based, or combined impedance-pH monitoring) off PPIs in patients with an endoscopy showing long-segment BE or severe reflux esophagitis (Los Angeles grade C or D).
C
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  • Biomarkers

Diagnostic procedures

Upper gastrointestinal endoscopy
As per ACG 2022 guidelines:
Consider taking at least 8 endoscopic biopsies in screening examinations with endoscopic findings consistent with possible BE, with the Seattle protocol followed for segments of > 4 cm.
C
Confirm dysplasia of any grade detected on biopsies of BE by a second pathologist with expertise in gastrointestinal pathology.
B
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  • EUS

  • Transnasal endoscopy

Medical management

PPIs, indications
As per ESGE 2023 guidelines:
Consider initiating PPIs (standard dose once daily) for chemoprevention in patients with BE.
C
Initiate adequate acid suppression therapy during and after endoscopic eradication therapy of BE.
B
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  • PPIs (considerations for long-term therapy)

  • NSAIDs

  • Management of esophageal adenocarcinoma

Therapeutic procedures

Endoscopic therapy, indications, no dysplasia: as per AGA 2024 guidelines, avoid performing endoscopic eradication therapy in patients with nondysplastic BE.
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  • Endoscopic therapy (indications, low-grade dysplasia)

  • Endoscopic therapy (indications, high-grade dysplasia)

  • Endoscopic therapy (technical considerations)

Surgical interventions

Antireflux surgery: as per ACG 2022 guidelines, avoid performing antireflux surgery as an antineoplastic measure in patients with BE.
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Patient education

General counseling: as per ACG 2022 guidelines, counsel patients with BE planned to undergo endoscopic eradication therapy to ensure they have a clear understanding of the risks and benefits associated with treatment.
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Follow-up and surveillance

Indications for referral: as per AGA 2022 guidelines, refer patients with BE-related neoplasia to endoscopists with expertise in advanced imaging, resection, and ablation.
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  • Surveillance endoscopy (choice of modality)

  • Surveillance endoscopy (intervals)

  • Surveillance endoscopy (patients without dysplasia)

  • Surveillance endoscopy (patients with dysplasia)

  • Surveillance endoscopy (post-treatment)

  • Surveillance endoscopy (discontinuation)

  • Management of recurrent metaplasia or dysplasia