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Screening and Surveillance for Barrett’s oesophagus

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Screening and Surveillance for Barrett’s oesophagus

Barrett’s oesophagus is typically diagnosed on endoscopy: the characteristic appearance of a Barrett’s oesophagus is shown in Figure 2. In addition to endoscopy, a biopsy is performmed. This involves taking a sample of tissue from the oesophagus to examine it under microscope. As mentioned before, the usual squamous cellular structure is replaced with a columnar cellular structure.

In medicine, screening is a technique used to identify disease in patients who do not currently have any characteristic signs / symptoms of the disease. For Barrett’s oesophagus, there is no evidence that screening lowers the mortality rate; as such, screening for the disease remains controversial (1) and is not offered to the general population. However, screening is recommended in the following high-risk patient groups (2):

EITHER:

  • At least one first-degree relative with either Barrett’s Oesophagus OR oesophageal carcinoma
  • AND evidence of chronic or severe gastro-oesophageal reflux disease

OR:

  • Evidence of chronic or severe gastro-oesophageal reflux disease
  • AND at least thee of:
    • Gender: male
    • Race: Caucasian
    • Obesity
    • Smoker
    • Age: 50+

Surveillance of Barrett’s oesophagus

After a diagnosis of Barrett’s Oesophagus, surveillance programmes are used to monitor the progression of disease and identify complications as early as possible. In Barrett’s oesophagus, surveillance programmes involve regular (upper gastrointestinal) endoscopic procedures to identify dysplasia (the development of abnormal cells that represent a pre-cancerous stage) or cancer. Dysplasia can be graded according to its severity, with high-grade dysplasia being a more severe state than low-grade dysplasia. Dysplasia is detected using high-resolution, white-light endoscopy with biopsies (3). If malignant disease is detected early enough, interventions can be introduced to reduce disease mortality.

Although dysplasia is a pre-cursor to adenocarcinoma in Barrett’s patients, some patients with non-dysplatic Barrett’s oesophagus may also develop oesophageal adenocarcinoma. The yearly percentage progression to adenocarcinoma is 0.33% in patients with non-dysplatic disease compared to 10% in patients with dysplastic adenocarcinoma (4,5).

The guidelines for surveillance of Barrett’s oesophagus (a) is not recommended if life-expectancy is <5 years and (b) varies depending on the gastroenterology society. In addition to disease surveillance, doctors need to:

  • Decide if treatment is appropriate and which treatment to provide
  • Control the symptoms associated with GORD

Patients with a <3cm Barrett’s oesophagus segment and without intestinal metaplasia (the cells change from flat to columnar in appearance)should be discharged from a surveillance programme. This needs to be confirmed on two successive endoscopies. However, if intestinal metaplasia is present, the patient should not be discharged (6).

  1. Sharma P, Sidorenko EI. Are screening and surveillance for Barrett’s oesophagus really worthwhile? Gut [Internet]. 2005 Mar;54(suppl{_}1):i27--i32. Available from: http://gut.bmj.com/cgi/doi/10.1136/gut.2004.041566
  2. Pophali P, Halland M. Barrett’s oesophagus: diagnosis and management. BMJ [Internet]. British Medical Journal Publishing Group; 2016;353(6):i2373. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27169585
  3. Levine DS, Haggitt RC, Blount PL, Rabinovitch PS, Rusch VW, Reid BJ. An endoscopic biopsy protocol can differentiate high-grade dysplasia from early adenocarcinoma in Barrett’s esophagus. Gastroenterology [Internet]. 1993 Jul;105(1):40–50. Available from: http://www.ncbi.nlm.nih.gov/pubmed/8514061
  4. Sikkema M, de Jonge PJF, Steyerberg EW, Kuipers EJ. Risk of esophageal adenocarcinoma and mortality in patients with Barrett’s esophagus: a systematic review and meta-analysis. Clin Gastroenterol Hepatol [Internet]. 2010 Mar;8(3):235--44; quiz e32. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19850156
  5. Hvid-Jensen F, Pedersen L, Drewes AM, Sørensen HT, Funch-Jensen P. Incidence of Adenocarcinoma among Patients with Barrett’s Esophagus. N Engl J Med [Internet]. 2011 Oct;365(15):1375–83. Available from: http://www.nejm.org/doi/abs/10.1056/NEJMoa1103042
  6. Shaheen NJ, Falk GW, Iyer PG, Gerson LB, American College of Gastroenterology. ACG Clinical Guideline: Diagnosis and Management of Barrett’s Esophagus. Am J Gastroenterol [Internet]. 2016 Jan;111(1):30--50; quiz 51. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26526079