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A 62-year-old, Caucasian male presents for a 6-month history of nausea and abdominal discomfort​. He reports a 10-year history of heartburn at least 4 times per week, taking calcium carbonate for relief. He has never had an upper endoscopy. His BMI is 31.  ​He has a family history of Barrett’s esophagus.

Screening for Barrett’s esophagus is suggested for patients with chronic GERD symptoms and 3 or more additional risk factors for Barrett’s esophagus except?​

1. Age >50 years
2. Caucasian race
3. Obesity
4. Tobacco smoking
5. Current or history of alcohol use

PRACTICE PEARLS

Screening

• Screening for Barrett’s esophagus is recommended in patients with a history of chronic gastroesophageal reflux disease symptoms and 3 or more additional risk factors for Barrett’s esophagus including male sex, age greater than 50 years, white race, tobacco smoking, obesity, family history of Barrett’s esophagus or esophageal adenocarcinoma in a first-degree relative.¹
• Counsel patients on benefits and risks, consider financial and time considerations as well as patient comorbidities.¹

Diagnosis

• The diagnosis of Barrett’s esophagus requires extension of columnar epithelium in the tubular esophagus greater than or equal to 1 cm above the gastroesophageal junction and histological evidence of specialized intestinal metaplasia.¹
• Barrett’s esophagus is best described by using the Prague criteria that includes both the circumferential and maximal (C-M) extent of the columnar epithelium.⁴
• At least 8 biopsies from the Barrett’s segment are required.¹
• Careful examination for mucosal irregularities (lumps or bumps harboring nests of dysplasia or cancer)

Image from personal library of Sarel Myburgh

Gastroesophageal reflux disease

• Patients with grade C or D esophagitis require follow-up endoscopy in 2-3 months after twice daily high-dose PPI therapy.^2-3 
• It is estimated that up to 15% of patients with erosive esophagitis will have Barrett’s found at endoscopy after healing erosive esophagitis.³
• Patients with Barrett’s should be on at least once daily proton pump inhibitor (PPI) if they have no allergy or contraindication to PPI.¹
• Continue aggressive lifestyle modifications for gastroesophageal reflux disease including head of bed elevation, weight loss for those who are overweight or obese, avoiding meals 2-3 hours before bedtime and smoking cessation.²
  

Management

• Endoscopic surveillance is performed at the intervals based on the degree of dysplasia noted.¹
• Segments of ≥3 cm surveyed on 3-year interval while segments of ​< 3 cm surveyed on 5-year interval.¹
• Endoscopic surveillance should employ four-quadrant biopsies at 2 cm intervals in patients without dysplasia and 1 cm intervals in patients with prior dysplasia.¹
• Barrett’s with dysplasia, review pathology slides by expert pathologist â€‹as there is considerable interobserver variability and it is more difficult to interpret low grade dysplasia and indefinite for dysplasia.¹
• Endoscopic eradication is recommended in patients with low-grade and high-grade dysplasia to prevent progression to esophageal adenocarcinoma.¹
• Modalities for endoscopic eradication include endoscopic mucosal resection, radiofrequency ablation and cryoablation.¹
• The goal of endoscopic therapy is complete remission of dysplasia and finally complete remission of intestinal metaplasia.¹
• Consider referral to center of expertise as treatment at high-volume centers is associated with reduced risk of recurrence.⁵

REFERENCES

1. Shaheen, Nicholas J. MD, MPH¹; Falk, Gary W. MD, MS²; Iyer, Prasad G. MD, MS³; Souza, Rhonda F. MD⁴; Yadlapati, Rena H. MD, MHS (GRADE Methodologist)⁵; Sauer, Bryan G. MD, MSc (GRADE Methodologist)⁶; Wani, Sachin MD⁷. Diagnosis and Management of Barrett's Esophagus: An Updated ACG Guideline. The American Journal of Gastroenterology 117(4): p 559-587, April 2022. | DOI: 10.14309/ajg.0000000000001680
2. Katz, Philip O. MD, MACG¹; Dunbar, Kerry B. MD, PhD^2,3; Schnoll-Sussman, Felice H. MD, FACG¹; Greer, Katarina B. MD, MS, FACG⁴; Yadlapati, Rena MD, MSHS⁵; Spechler, Stuart Jon MD, FACG^6,7. ACG Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease. The American Journal of Gastroenterology 117(1):p 27-56, January 2022. | DOI: 10.14309/ajg.0000000000001538
3. Wang, Kenneth K. M.D.; Sampliner, Richard E. M.D. Updated Guidelines 2008 for the Diagnosis, Surveillance and Therapy of Barrett's Esophagus. American Journal of Gastroenterology 103(3):p 788-797, March 2008.
4. Clermont M, Falk GW. Clinical Guidelines Update on the Diagnosis and Management of Barrett's Esophagus. Dig Dis Sci. 2018 Aug;63(8):2122-2128. doi: 10.1007/s10620-018-5070-z. PMID: 29671159.
5. Tan MC, Kanthasamy KA, Yeh AG, Kil D, Pompeii L, Yu X, El-Serag HB, Thrift AP. Factors Associated With Recurrence of Barrett's Esophagus After Radiofrequency Ablation. Clin Gastroenterol Hepatol. 2019 Jan;17(1):65-72.e5. doi: 10.1016/j.cgh.2018.05.042. Epub 2018 Jun 11. PMID: 29902646.

Author

Sarel J. Myburgh, APRN, CNP, MS is a Nurse Practitioner Specialist with over ten years of diverse experiences in Rochester, Minnesota and affiliates with many hospitals in the Mayo Clinic Health System. He currently serves on the ¶¶Òô´ó¹Ï APP Committee.