Guideline sources The following summarized guidelines for the evaluation and management of Barrett's esophagus (BE) are prepared by our editorial team based on guidelines from the United European Gastroenterology (UEG/ESPEN 2023), the American Gastroenterological Association (AGA 2022; 2012), the American College of Gastroenterology (ACG 2022; 2016; 2013), the American Society for Gastrointestinal Endoscopy (ASGE 2019; 2018), the British Society of Gastroenterology (BSG 2018), and the European Society of Gastrointestinal Endoscopy (ESGE 2017). 1 2 3 4 5 6 7 8 9 10 11 11 11 11 12 Definition BE is a pre-neoplastic condition characterized by intestinal metaplasia of the esophageal squamous mucosa. 11 Epidemiology In patients with BE, cellular damage to the esophageal mucosa is caused by chronic acid-induced mucosal injury associated with GERD. 11 Pathophysiology https://web.pathway.md/diseases/recHRXYnA7BRzX4gP 1/10 6/29/23, 3:16 AM Barrett's esophagus Pathway Pathophysiology In the United States, the prevalence of BE is estimated at 5600 persons per 100,000 population. 12 Disease course Chronic inflammation leads to activation of oncogenes and silencing of tumor suppressor genes, increasing the risk of esophageal adenocarcinoma and esophageal SCC. 11 Prognosis and risk of recurrence The rate of progression of high-grade dysplasia in patients with BE is approximately 6% per year. 11 Calculator Diagnostic criteria for Barrett's e Guidelines 1. Screening and diagnosis Indications for screening, general population: As per ASGE 2019 guidelines, insufficient evidence to recommend screening for BE. I As per ESGE 2017 guidelines, do not obtain endoscopic screening for BE in general population. D As per ACG 2016 guidelines, do not obtain screening for BE in the general population. D Indications for screening, high risk patients: As per ACG 2022 guidelines, consider performing a single screening endoscopy in patients with chronic GERD symptoms and 3 additional risk factors for BE, including: male gender age > 50 year white race tobacco smoking obesity family history of BE or esophageal adenocarcinoma in a first-degree relative. C Show 2 more As per AGA 2022 guidelines, consider obtaining endoscopic screening for BE in patients with 3 of the following risk factors for BE and esophageal adenocarcinoma: male gender https://web.pathway.md/diseases/recHRXYnA7BRzX4gP 2/10 6/29/23, 3:16 AM Barrett's esophagus Pathway non-Hispanic white race age > 50 years history of smoking chronic GERD obesity family history of BE or esophageal adenocarcinoma. C As per ASGE 2019 guidelines, consider adopting a screening strategy for BE, if performed, identifying at-risk population - individuals with a family history of esophageal adenocarcinoma or BE (high risk) or patients with GERD plus at least 1 other risk factor (moderate risk). C As per ESGE 2017 guidelines, consider obtaining endoscopic screening for BE in patients with longstanding GERD (> 5 years) and multiple risk factors, including: male gender age 50 years white race obesity first-degree relative with BE or esophageal adenocarcinoma. C Indications for screening (before bariatric surgery): consider performing upper gastrointestinal endoscopy as a routine diagnostic test before bariatric surgery to rule out Barret's esophagus or esophageal and gastric malignancies. C Technical considerations for screening: consider using nonendoscopic cell-collection devices as an option to screen for BE. C Show 5 more Diagnostic criteria: As per ACG 2022 guidelines: Consider diagnosing BE in the presence of intestinal metaplasia in the tubular esophagus. C Consider diagnosing BE in the presence of columnar mucosa of at least 1 cm in length: in patients with a normal-appearing Z line; do not perform routine endoscopic biopsies in patients with a Z line demonstrating < 1 cm of proximal displacement from the top of the gastric folds in the absence of any visible lesions; do not perform routine endoscopic biopsies. C As per ESGE 2017 guidelines, diagnose BE if the distal esophagus is lined with columnar epithelium with a minimum length of 1 cm (tongues or circular) containing specialized intestinal metaplasia at histopathological examination. B 2. Diagnostic investigations Biomarkers: do not use additional biomarkers for risk stratification of patients with BE. D https://web.pathway.md/diseases/recHRXYnA7BRzX4gP 3/10 6/29/23, 3:16 AM Barrett's esophagus Pathway 3. 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 As per ASGE 2018 guidelines, consider confirming the diagnosis of BE in patients with low- and high-grade dysplasia being candidates for endoscopic eradication therapy by at least one expert gastrointestinal pathologist or panel of pathologists. C As per ESGE 2017 guidelines, include the following in the endoscopy reports of patients with BE: the extent of BE using the Prague criteria (circumferential extent, C; maximum extent, M) and any separate islands proximal to the maximal extent a description of location (in cm from the incisors and clockwise orientation) of any visible abnormality within the Barrett's epithelium, in addition to lesion size (mm) and macroscopic appearance using the Paris classification the presence or absence of erosive esophagitis using the Los Angeles classification the location of biopsies taken from the Barrett's segment (number of biopsies and location in cm from the incisors) appropriate photo documentation of the landmarks and of all visible Barrett's epithelium and any visible lesions. B Show 2 more As per ACG 2016 guidelines: Document the extent of metaplastic change including circumferential and maximal segment length using the Prague classification. B Document the location of the diaphragmatic hiatus, GEJ, and squamocolumnar junction in the endoscopy report. B Endoscopic ultrasound: As per AGA 2022 guidelines, perform biopsy in patients with erosive esophagitis if concerns of dysplasia or malignancy exist. B Show 3 more As per ACG 2016 guidelines: Insufficient evidence to recommend routine staging of patients with nodular BE with EUS or other imaging modalities before endoscopic mucosal resection. Do not deter from performing endoscopic mucosal resection to stage early neoplasia solely based on EUS findings, given the possibility of over-staging and under-staging. I https://web.pathway.md/diseases/recHRXYnA7BRzX4gP 4/10 6/29/23, 3:16 AM Barrett's esophagus Pathway Consider obtaining EUS to assess and sample regional lymph nodes in patients with known T1b disease, given the increased prevalence of lymph node involvement in these patients compared with less advanced disease. B Transnasal endoscopy: consider performing unsedated transnasal endoscopy as an alternative to conventional upper endoscopy for BE screening. B 4. Medical management Proton pump inhibitors: As per ACG 2022 guidelines: Consider initiating at least once daily PPI therapy in patients with BE without allergy or other contraindication to PPI use. C Insufficient evidence to support the use of combination therapy with aspirin and PPIs in patients with BE. I As per AGA 2022 guidelines, initiate daily PPI therapy in all patients with BE. B As per ACG 2016 guidelines: Initiate once-daily PPI therapy in patients with BE. Do not use twice-daily dosing routinely unless required because of poor control of reflux symptoms or esophagitis. B Set the goal of medical antireflux therapy following complete eradication of intestinal metaplasia to control reflux, as determined by the absence of frequent reflux symptoms (> 1 per week) and/or esophagitis on endoscopic examination. B As per ACG 2013 guidelines, treat symptoms in patients with BE in a similar fashion to patients with GERD not having BE. B Nonsteroidal anti-inflammatory drugs: avoid prescribing aspirin or NSAIDs routinely as an antineoplastic strategy in patients with BE. D Management of esophageal adenocarcinoma: As per ESGE 2017 guidelines: Perform endoscopic resection as the first-choice therapy in patients with T1a esophageal adenocarcinoma. B Decide on the optimal treatment strategy depending on histopathological characteristics of the endoscopic resection specimen in patients with T1b esophageal adenocarcinoma. Consider performing endoscopic resection as a valid alternative to surgery in patients at borderline fit for surgery, if the endoscopic resection specimen meets all of the following criteria: Situation Guidance Limited to < 500 mcm Submucosal invasion Well or moderate Tumor differentiation grade Absent https://web.pathway.md/diseases/recHRXYnA7BRzX4gP 5/10 6/29/23, 3:16 AM Barrett's esophagus Pathway Tumor invasion in lymphatic vessels or blood vessels Absent. B Tumor infiltration in the deep resection margin As per ACG 2016 guidelines, perform esophagectomy, with consideration of neoadjuvant therapy, in patients with esophageal adenocarcinoma with invasion into the submucosa, especially if invasion to the mid- or deep submucosa (T1b, sm2-3) is present. B 5. Therapeutic procedures Endoscopic therapy: As per ACG 2022 guidelines, counsel patients with BE embarking on endoscopic eradication therapy to ensure a clear understanding of the risks and benefits associated with these therapies before the initiation of therapy. Show 5 more As per ASGE 2018 guidelines, consider preferring endoscopic eradication therapy over surveillance in patients with low-grade dysplasia. C Show 5 more As per ESGE 2017 guidelines, do not perform prophylactic endoscopic therapy (such as ablation therapy) for non-neoplastic BE. D Show 3 more 6. Surgical interventions Antireflux surgery: avoid performing antireflux surgery as an antineoplastic measure in patients with BE. D 7. 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. B As per ESGE 2017 guidelines: Refer all patients with a BE 10 cm, a confirmed diagnosis of low-grade dysplasia, high-grade dysplasia or early cancer to a BE expert center for surveillance and/or treatment. B Ensure that a BE expert center meets the following requirements: annual case load of 10 new patients with endoscopic treatment for high-grade dysplasia or early carcinoma per BE expert endoscopist https://web.pathway.md/diseases/recHRXYnA7BRzX4gP 6/10 6/29/23, 3:16 AM Barrett's esophagus Pathway endoscopic and histological care is provided by endoscopists and pathologists participated additional training in this field (either by courses or guest visits) and, a minimum of 30 supervised cases of endoscopic resection and 30 cases of endoscopic ablation should be performed to acquire competence in technical skills, management pathways, and complications patients with Barrett's neoplasia are discussed in multidisciplinary meetings with gastroenterologists, surgeons, oncologists and pathologists access to experienced esophageal surgery all patients with BE are registered prospectively in a database. B Surveillance endoscopy, general principles: As per ACG 2022 guidelines, perform both white light endoscopy and chromoendoscopy in patients undergoing endoscopic surveillance of BE. B Show 6 more As per ASGE 2019 guidelines, perform chromoendoscopy, including virtual chromoendoscopy and Seattle protocol biopsy sampling, in patients with BE undergoing surveillance. B Show 3 more As per ESGE 2017 guidelines, obtain endoscopic surveillance in patients with BE. B Show 4 more As per AGA 2012 guidelines, do not obtain surveillance examination within 3 years in patients with BE with a second endoscopy confirming the absence of dysplasia on biopsy. D Surveillance endoscopy, patients without dysplasia: As per AGA 2022 guidelines, perform surveillance endoscopy in 3-5 years in patients with nondysplastic BE. B As per ASGE 2019 guidelines, consider performing surveillance endoscopy in patients with nondysplastic BE. C As per ACG 2016 guidelines: Consider performing repeat endoscopy at 1-2 years to rule out BE in patients with suspected BE and lack of intestinal metaplasia on histology. C Do not perform repeat endoscopy if the initial endoscopy is negative for BE. Perform repeat endoscopy after PPI therapy for 8-12 weeks if endoscopy reveals esophagitis (Los Angeles Classification B, C, or D), to ensure healing of esophagitis and exclude the presence of underlying BE. D Surveillance endoscopy, patients with dysplasia: As per ASGE 2019 guidelines, do not obtain routine EUS to differentiate mucosal versus submucosal disease in patients with BE with high-grade dysplasia/intramucosal cancer or nodules. D As per ASGE 2018 guidelines, consider obtaining surveillance over endoscopic eradication therapy in patients with low-grade dysplasia placing a high value on avoiding adverse events related to endoscopic eradication therapy. C https://web.pathway.md/diseases/recHRXYnA7BRzX4gP 7/10 6/29/23, 3:16 AM Barrett's esophagus Pathway As per BSG 2018 guidelines: Perform a repeat endoscopy at 6 months in patients with low-grade dysplasia. B Offer endoscopic ablation therapy, preferably with radiofrequency ablation and after a review by a specialist multidisciplinary team, in patients with low-grade dysplasia in any of the follow- up endoscopy (confirmed by an expert gastrointestinal pathologist in at least 2 sets of biopsies). Offer 6-monthly surveillance if ablation is not performed. A As per ESGE 2017 guidelines, optimize antireflux therapy and perform repeated endoscopy at 6 months in patients with a diagnosis of "indefinite for dysplasia" confirmed by a second expert gastrointestinal pathologist. Obtain surveillance as in patients with nondysplastic BE if no definite dysplasia is found in subsequent biopsy samples (including if the biopsies are again classified as "indefinite for dysplasia"). B Show 2 more As per ACG 2016 guidelines, obtain endoscopic surveillance at intervals of 3-5 years in patients with BE without dysplasia. B Show 2 more Surveillance endoscopy, post-treatment: As per ACG 2022 guidelines, obtain endoscopic surveillance in patients with BE successfully completed endoscopic eradication therapy. B As per AGA 2022 guidelines: Perform repeat endoscopy after 8 weeks of BID PPI therapy. B Take random biopsies of the esophagogastric junction, gastric cardia, and the distal 2 cm of the neosquamous epithelium and from all visible lesions, independent of the length of the original BE segment, in patients undergoing surveillance after endoscopic eradication therapy. B As per ASGE 2018 guidelines, consider performing surveillance endoscopy in patients with dysplasia and intramural cancer achieved complete eradication of intestinal metaplasia after endoscopic eradication therapy. C As per ACG 2016 guidelines, continue endoscopic surveillance to detect recurrent intestinal metaplasia and/or dysplasia following successful endoscopic therapy and complete eradication of intestinal metaplasia. B Show 3 more Management of recurrent metaplasia or dysplasia: treat recurrent metaplasia and/or dysplasia according to the same guidelines as for the treatment of metaplasia/dysplasia prior to ablation. B Clinical findings Patient demographics Symptoms Age > 50 Chest pain Male sex Dysphagia https://web.pathway.md/diseases/recHRXYnA7BRzX4gP 8/10 6/29/23, 3:16 AM Barrett's esophagus Pathway White race Food regurgitation Heartburn Past medical history Weight loss GERD Family history Obesity Genetic predispositions Social history Lab findings Current cigarette smoking Iron deficiency Histological findings Dysplasia in the distal esophagus Intestinal metaplasia in the distal esophagus References 1. V Raman Muthusamy, Sachin Wani, C Prakash Gyawali et al. AGA Clinical Practice Update on New Technology and Innovation for Surveillance and Screening in Barrett's Esophagus: Expert Review. Clin Gastroenterol Hepatol. 2022 Dec;20 12 2696 2706.e1. Open 2. ASGE STANDARDS OF PRACTICE COMMITTEE, Bashar Qumseya, Shahnaz Sultan et al. ASGE guideline on screening and surveillance of Barrett's esophagus. Gastrointest Endosc. 2019 Sep;90 3 335 359.e2. Open 3. Shaheen NJ, Falk GW, Iyer PG et al. ACG Clinical Guideline: Diagnosis and Management of Barrett's Esophagus. Am J Gastroenterol. 2016 Jan;111 1 30 50. Open 4. Bas Weusten, Raf Bisschops, Emanuel Coron et al. Endoscopic management of Barrett's esophagus: European Society of Gastrointestinal Endoscopy ESGE Position Statement. Endoscopy. 2017 Feb;49 2 191 198. Open 5. Standards of Practice Committee, Sachin Wani, Bashar Qumseya et al. Endoscopic eradication therapy for patients with Barrett's esophagus-associated dysplasia and intramucosal cancer. Gastrointest Endosc. 2018 Apr;87 4 907 931.e9. Open 6. Massimiliano di Pietro, Rebecca C Fitzgerald, BSG Barrett's guidelines working group. Revised British Society of Gastroenterology recommendation on the diagnosis and management of Barrett's oesophagus with low-grade dysplasia. Gut. 2018 Feb;67 2 392 393. Open 7. Nicholas J Shaheen, Gary W Falk, Prasad G Iyer et al. Diagnosis and Management of Barrett's Esophagus: An Updated ACG Guideline. Am J Gastroenterol. 2022 Apr 1;117 4 559 587. Open 8. Katz PO, Gerson LB, Vela MF. Guidelines for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroenterol. 2013 Mar;108 3 308 28. Open 9. American Gastroenterological Association. Choosing Wisely: Recommendations of the American Gastroenterological Association. Choosing Wisely. 2012 Apr. Open https://web.pathway.md/diseases/recHRXYnA7BRzX4gP 9/10 6/29/23, 3:16 AM Barrett's esophagus Pathway 10. Stephan C Bischoff, Johann Ockenga, Ahad Eshraghian et al. Practical guideline on obesity care in patients with gastrointestinal and liver diseases Joint ESPEN/UEG guideline. Clin Nutr. 2023 Apr 10;42 6 987 1024. Open 11. Spechler SJ, Souza RF. Barrett's esophagus. N Engl J Med. 2014 Aug 28;371 9 836 45. Open 12. Kuipers EJ. Barrett esophagus and life expectancy: implications for screening?. Gastroenterol Hepatol N Y . 2011 Oct;7 10 689 91. Open 13. American Gastroenterological Association. Choosing Wisely AGA recommendations. Choosing Wisely. 2012. Open 14. Laura E Targownik, Deborah A Fisher, Sameer D Saini. AGA Clinical Practice Update on De-Prescribing of Proton Pump Inhibitors: Expert Review. Gastroenterology. 2022 Feb 16;S0016 5085 21 04083 X. Open 15. Barbara Farrell, Kevin Pottie, Wade Thompson et al. Deprescribing proton pump inhibitors: Evidence- based clinical practice guideline. Can Fam Physician. 2017 May;63 5 354 364. Open 16. Roos E Pouw, Maximilien Barret, Katharina Biermann et al. Endoscopic tissue sampling Part 1 Upper gastrointestinal and hepatopancreatobiliary tracts. European Society of Gastrointestinal Endoscopy ESGE Guideline. Endoscopy. 2021 Nov;53 11 1174 1188. Open https://web.pathway.md/diseases/recHRXYnA7BRzX4gP 10/10