The American College of Gastroenterology (ACG) has significantly changed the clinical guideline on the diagnosis and management of Barrett's esophagus (BE), citing major advances in the use of endoscopic ablative therapy, data supporting less frequent endoscopic surveillance for patients with nondysplastic BE, and data showing that most women with gastroesophageal reflux disease can safely skip routine BE screening.
Nicholas J. Shaheen, MD, MPH, and colleagues published the new guideline online November 3 in the American Journal of Gastroenterology. Dr Shaheen is professor of medicine and epidemiology and director of the Center for Esophageal Diseases & Swallowing, Division of Gastroenterology & Hepatology, University of North Carolina School of Medicine, Chapel Hill.
The most notable changes reflect rapid advances in BE treatment. "No aspect of these guidelines has evolved more since the last guideline iteration than therapeutic aspects of BE. Most profound of these changes is our markedly augmented ability to provide effective endoscopic therapy for subjects with neoplastic BE," the authors write.
The new guideline includes expanded recommendations on methods for close inspection of the BE mucosa to inform decisions on endoscopic therapy. The preferred approach includes identification of mucosal irregularities (nodularity, ulceration, flat but irregular mucosal contour) with adjunct use of narrow light spectrum imaging technology such as narrow-band imaging. Clinicians should address irregularities with endoscopic mucosal resection (EMR) or endoscopic submucosal dissection, both for treatment and for lesion staging.
The updated treatment recommendations include the expanded use of endoscopic ablative therapy, now including use in patients with low-grade dysplasia (LGD). This change was based on data from a randomized clinical trial that compared radiofrequency ablation with endoscopic surveillance in such patients and found a significantly lower risk for progression and/or adenocarcinoma after ablation.
In patients with nondysplastic BE and no dysplasia on EMR, the ACG recommends against endoscopic ablative therapies because of the low risk for progression to esophageal adenocarcinoma. The ACG recommends endoscopic surveillance only every 3 to 5 years.
In patients with LGD or high-grade dysplasia whose lesions were completely resected, EMR should be followed by endoscopic ablative therapy to decrease risk for recurrent dysplasia. However, the authors also stress the importance of having the diagnosis of LGD confirmed by a second pathologist with extensive experience in Barrett's associated neoplasia, citing studies showing that 73% to 85% of patients diagnosed with LGD in the community were downgraded to no dysplasia or indefinite for dysplasia after such review.
In view of the growing importance of endoscopic ablative therapy, the ACG recommended that all clinicians who practice endoscopic ablative procedures also offer EMR, which is typically required before application of radiofrequency ablation.
Patients with confirmed LGD should receive aggressive proton pump inhibitor antisecretory therapy, followed by repeat endoscopy. Patients with LGD confirmed after that examination who do not have endoscopic therapy should have annual surveillance until two examinations are negative for dysplasia.
New Guidance on BE Diagnosis and Monitoring
The BE guideline also includes reductions in some earlier diagnostic and monitoring recommendations. The most notable is that women with gastroesophageal reflux disease symptoms are no longer candidates for routine endoscopic screening in the absence of multiple risk factors such as age older than 50 years, Caucasian race, chronic and/or frequent gastroesophageal reflux disease, central obesity, waist circumference larger than 88 cm, smoking, or confirmed family history of BE or esophageal adenocarcinoma. This was based on data from the Surveillance, Epidemiology, and End Results database showing that women are at very low risk for esophageal adenocarcinoma. Routine screening for BE is recommended only for men with reflux symptoms and multiple other risk factors.
Routine use of biomarker panels and advanced endoscopic imaging techniques (beyond high-definition endoscopy) were judged not ready for prime time and are not recommended.
However, the authors expect changes to come fairly quickly and to be major. "Several areas in particular appear poised for paradigm-shifting advances. These include the evolution of biomarkers to predict risk in BE, the use of advanced imaging and biomolecular technologies to allow recognition of areas of neoplasia within BE, and the advent of less invasive and less expensive modalities for screening patients for BE," they write.
Dr Shaheen receives research funding from Covidien, CSA Medical, NeoGenomics, GI Dynamics, Takeda Pharmaceuticals, and CDx Diagnostics. One coauthor receives research funding from CDx Diagnostics and is a consultant for Takeda Pharmaceuticals, Endogastric Solutions, Mederi Therapeutics, and Medigus. Another coauthor receives research funding from Intromedic Inc. Another coauthor receives research funding from CDx Diagnostics.
Am J Gastroenterol. Published online November 3, 2015. Full text