Updated Guidelines 2008 for the Diagnosis, Surveillance and Therapy of Barrett's Esophagus

Abstract

PREAMBLE The guidelines for the diagnosis, surveillance and therapy of Barrett's esophagus were originally published by the American College of Gastroenterology in 1998 and updated in 2002. These and other guidelines undergo periodic review. Significant advances have occurred in the area of Barrett's esophagus over the past four years leading to another revision of the prior guidelines. These advances include the potential use of esophageal capsule endoscopy for the diagnosis and screening of Barrett's esophagus, data regarding the outcome of low-grade dysplasia, the treatment of high-grade dysplasia using photodynamic therapy, and the development of new ablation techniques such as radiofrequency ablation. These guidelines are intended to be applied by physicians who see Barrett's esophagus patients and are intended to indicate a preferred, but certainly not the only, acceptable approach. Physicians need to choose the course best suited to the individual patient and to the variables that exist at the time of decision making. The guidelines are for adult patients with the diagnosis of Barrett's esophagus, as defined herein. Both these and the original guidelines were developed under auspices of the American College of Gastroenterology and the Practice Parameters Committee and approved by the Board of Trustees. The world literature was reviewed extensively for the original guidelines and once again reviewed using the National Library of Medicine database. Search terms used included Barrett's esophagus, esophageal neoplasm, esophagus, intestinal metaplasia, esophageal diseases, and adenocarcinoma, all appropriate studies and any additional ones found in reference to these papers were obtained and reviewed. Evidence was available from a hierarchy of trials and randomized controlled trials were given the greatest weight. Abstracts presented at national and international meetings were only used when unique data from ongoing trials were presented. When scientific data were lacking, recommendations are based on expert opinion. The recommendations made are based on the level of evidence found. Grade A recommendations imply that there is consistent level 1 evidence (randomized controlled trials), Grade B indicates that the evidence would be level 2 or 3 which are cohort studies or case control studies. Grade C recommendations are based on level 4 studies meaning case series or poor quality cohort studies, and Grade D recommendations are based on level 5 evidence meaning expert opinion. SIGNIFICANCE OF BARRETT'S ESOPHAGUS Barrett's esophagus continues to be increasingly recognized in the United States and is believed to be the major risk factor for the development of esophageal adenocarcinoma. The incidence of adenocarcinoma of the esophagus continues to rise rapidly. The rate of rise is alarming and is widespread in Western countries. In a review by the epidemiologists of the National Cancer Institute of cancer incidences normalized to the year 1975, esophageal adenocarcinoma incidence rates were found to outpace even those of melanoma, breast cancer and prostate cancer in terms of the rapidity of rise (1). These epidemiologists also found there was no concomitant decrease in diagnoses of gastric cancers or more proximal cancers, making a classification change unlikely to be responsible for this increase in adenocarcinoma. In the Danish Cancer Registry, adenocarcinoma incidence rates actually decrease in patients older than 85 (14.14/100,00 (80–84 yr) decreasing to 7.2/100,000 (85+ yr) unlike squamous cancer rates suggesting that this rise in adenocarcinoma incidence may be truly a recent phenomenon as evidenced by this age cohort effect (2). DEFINITION OF BARRETT'S ESOPHAGUS Barrett's esophagus is a change in the distal esophageal epithelium of any length that can be recognized as columnar type mucosa at endoscopy and is confirmed to have intestinal metaplasia by biopsy of the tubular esophagus. (Grade B recommendation). This working definition of Barrett's esophagus has changed little over the last 10 years. A recent “critical review of the diagnosis” of Barrett's esophagus concluded that “the working definition of BE is displacement of the squamocolumnar junction proximal to the gastroesophageal junction” and “endoscopy with multiple systematic biopsies is needed to establish the diagnosis of Barrett's esophagus” (3). This definition does not distinguish between short and long segment Barrett's esophagus and implies that only columnar lined esophagus should be biopsied. Although intestinal metaplasia is not specifically mentioned in this definition, clearly the reason to do multiple biopsies in the columnar appearing esophagus is to identify the presence of intestinal metaplasia, the premalignant lesion for esophageal adenocarcinoma (EAC). The vast majority of adenocarcinomas of the esophagus are accompanied by intestinal metaplasia in multiple cohort studies (4–8) and many adenocarcinomas of the esophagogastric j