Diagnosis and Management of Barrett’s Esophagus

Publication Date: January 1, 2016
Last Updated: April 1, 2022

Recommendations

Diagnosis of BE

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.

(Strong  “We recommend”, Low)
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2. Endoscopic biopsy should not be performed in the presence of a normal Z line or a Z line with <1 cm of variability.

(Strong  “We recommend”, Low)
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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.

(Conditional (weak)  “We suggest”, Low)
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4. The location of the diaphragmatic hiatus, gastroesophageal junction, and squamocolumnar junction should be reported in the endoscopy report.

(Conditional (weak)  “We suggest”, Low)
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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.

(Conditional (weak)  “We suggest”, Low)
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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.

(Conditional (weak)  “We suggest”, Very low)
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Screening for 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).

(Strong  “We recommend”, Moderate)
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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)).

(Strong  “We recommend”, Low)
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9. Screening of the general population is not recommended.

(Conditional (weak)  “We suggest”, Low)
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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.

(Strong  “We recommend”, Very low)
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11. Unsedated transnasal endoscopy (uTNE) can be considered as an alternative to conventional upper endoscopy for BE screening.

(Strong  “We recommend”, Low)
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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.

(Conditional (weak)  “We suggest”, Low)
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Surveillance of BE

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

(Strong  “We recommend”, Very low)
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14. Surveillance should be performed with high-definition/high-resolution white light endoscopy.

(Strong  “We recommend”, Low)
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15. Routine use of advanced imaging techniques other than electronic chromoendoscopy is not recommended for endoscopic surveillance at this time.

(Conditional (weak)  “We suggest”, Very low)
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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.

(Strong  “We recommend”, Low)
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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.

(Strong  “We recommend”, Low)
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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.

(Strong  “We recommend”, Very low)
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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.

(Strong  “We recommend”, Moderate)
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20. Use of additional biomarkers for risk stratifi cation of patients with BE is currently not recommended.

(Strong  “We recommend”, Low)
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21. For BE patients without dysplasia, endoscopic surveillance should take place at intervals of 3 to 5 years.

(Strong  “We recommend”, Moderate)
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22. Patients diagnosed with BE on initial examination do not require a repeat endoscopy in 1 year for dysplasia surveillance.

(Conditional (weak)  “We suggest”, Very low)
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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.

(Strong  “We recommend”, Low)
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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.

(Strong  “We recommend”, Moderate)
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25. Patients with BE and confirmed high-grade dysplasia should be managed with endoscopic therapy unless they have life-limiting comorbidity.

(Strong  “We recommend”, High)
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Therapy

Chemoprevention

26. Patients with BE should receive once-daily PPI therapy. Routine use of twice-daily dosing is not recommended, unless necessitated because of poor control of reflux symptoms or esophagitis.

(Strong  “We recommend”, Moderate)
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27. Aspirin or NSAIDs should not be routinely prescribed to patients with BE as an antineoplastic strategy. Similarly, other putative chemopreventive agents currently lack sufficient evidence and should not be administered routinely.

(Conditional (weak)  “We suggest”, High)
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Endoscopic therapy

28. Patients with nodularity in the BE segment should undergo endoscopic mucosal resection of the nodular lesion(s) as the initial diagnostic and therapeutic maneuver (see point 17 above). Histologic assessment of the EMR specimen should guide further therapy. In subjects with EMR specimens demonstrating HGD, or IMC, endoscopic ablative therapy of the remaining BE should be performed.

(Strong  “We recommend”, High)
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29. In patients with EMR specimens demonstrating neoplasia at a deep margin, residual neoplasia should be assumed, and surgical, systemic, or additional endoscopic therapies should be considered.

(Strong  “We recommend”, Low)
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30. Endoscopic ablative therapies should not be routinely applied to patients with nondysplastic BE because of their low risk of progression to EAC.

(Strong  “We recommend”, Very low)

Endoscopic eradication therapy is the procedure of choice for patients with confi rmed LGD, and confirmed HGD, as noted above (see points 24 and 25).

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31. In patients with T1a EAC, endoscopic therapy is the preferred therapeutic approach, being both effective and well tolerated.

(Strong  “We recommend”, Moderate)
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32. In patients with T1b EAC, consultation with multidisciplinary surgical oncology team should occur before embarking on endoscopic therapy. In such patients, endoscopic therapy may be an alternative strategy to esophagectomy, especially in those with superficial (sm1) disease with a well-differentiated neoplasm lacking lymphovascular invasion, as well as those who are poor surgical candidates.

(Strong  “We recommend”, Low)
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33. Routine staging of patients with nodular BE with EUS or other imaging modalities before EMR has no demonstrated benefit. Given the possibility of over- and understaging, findings of these modalities should not preclude the performance of EMR to stage-early neoplasia.

(Strong  “We recommend”, Moderate)
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34. In patients with known T1b disease, EUS may have a role in assessing and sampling regional lymph nodes, given the increased prevalence of lymph node involvement in these patients compared with less advanced disease.

(Strong  “We recommend”, Moderate)
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35. In patients with dysplastic BE who are to undergo endoscopic ablative therapy for nonnodular disease, radiofrequency ablation is currently the preferred endoscopic ablative therapy.

(Strong  “We recommend”, Moderate)
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Surgical therapy

36. Antireflux surgery should not be pursued in patients with BE as an antineoplastic measure. However, this surgery should be considered in those with incomplete control of reflux symptoms on optimized medical therapy.

(Strong  “We recommend”, High)
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37. In cases of EAC with invasion into the submucosa, especially those with invasion to the mid or deep submucosa (T1b, sm2–3), esophagectomy, with consideration of neoadjuvant therapy, is recommended in the surgical candidate.

(Strong  “We recommend”, Low)
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38. In patients with T1a or T1b sm1 adenocarcinoma, poor differentiation, lymphovascular invasion, or incomplete endoscopic mucosal resection should prompt consideration of surgical and/or multimodality therapies.

(Strong  “We recommend”, Low)
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Management of BE after endoscopic therapy

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

(Strong  “We recommend”, Low)
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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.

(Conditional (weak)  “We suggest”, Low)
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41. In patients with LGD before ablation, endoscopic surveillance is recommended every 6 months in the first year following CEIM, and annually thereafter.

(Conditional (weak)  “We suggest”, Low)
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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.

(Strong  “We recommend”, Low)
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43. Treatment of recurrent metaplasia and/or dysplasia should follow guidelines for the treatment of metaplasia/dysplasia in BE before ablation.

(Strong  “We recommend”, Low)
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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.

(Conditional (weak)  “We suggest”, Very low)
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Endoscopic eradication therapy: training and education

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

(Strong  “We recommend”, Very low)
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Recommendation Grading

Overview

Title

Diagnosis and Management of Barrett’s Esophagus

Authoring Organization

American College of Gastroenterology

Publication Month/Year

January 1, 2016

Last Updated Month/Year

July 25, 2023

Supplemental Implementation Tools

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

Although many of the recommendations provided are based on weak evidence or expert opinion, this document provides a pragmatic framework for the care of the patient with Barrett's esophagus.

Target Patient Population

Patients with Barrett's esophagus

Inclusion Criteria

Female, Male, Adolescent, Adult, Older adult

Health Care Settings

Ambulatory, Hospital, Operating and recovery room, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Assessment and screening, Diagnosis, Management, Treatment

Diseases/Conditions (MeSH)

D001471 - Barrett Esophagus, D004935 - Esophageal Diseases, D004947 - Esophagus, D004945 - Esophagoscopy

Keywords

gastroesophageal reflux disease (GERD), Barrett's esophagus

Source Citation

Shaheen, Nicholas J MD, MPH, FACG; Falk, Gary W MD, MS, FACG; Iyer, Prasad G MD, MSc, FACG; Gerson, Lauren B MD, MSc, FACGACG Clinical Guideline: Diagnosis and Management of Barrett’s Esophagus, American Journal of Gastroenterology: January 2016 - Volume 111 - Issue 1 - p 30-50 doi: 10.1038/ajg.2015.322