ACG updates guidance for diagnosis, management of Barrett’s esophagus
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The ACG issued revised clinical guidelines for the diagnosis and management of patients with Barrett’s esophagus, which were published in the American Journal of Gastroenterology.
The guidelines implement Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology to propose 21 recommendations for the definition and diagnosis of BE, screening for both BE and esophageal adenocarcinoma (EAC), surveillance and treatment. Of note, the updates broaden acceptable screening modalities to include nonendoscopic methods, liberalized intervals for screening and volume criteria for therapy centers.
“We recommend endoscopic eradication therapy for patients with BE and high-grade dysplasia and those with BE and low-grade dysplasia. We propose structured surveillance intervals for patients with dysplastic BE after successful ablation based on the baseline degree of dysplasia,” Nicholas J. Shaheen, MD, MPH, chief of gastroenterology and hepatology at the University of North Carolina at Chapel Hill, and colleagues wrote. “We could not make recommendations regarding chemoprevention or use of biomarkers in routine practice due to insufficient data.”
Highlights of the guidelines include:
- At least eight endoscopic biopsies should be collected in screening examinations with endoscopic evidence consistent with possible BE.
- Dysplasia of any grade on biopsies of BE should be confirmed by a second GI pathologist.
- A single screening endoscopy should be performed in patients with chronic GERD symptoms and three or more additional risk factors for BE, which include male sex, age greater than 50 years, white race, tobacco use, obesity and a first-degree family history of BE or EAC.
- A swallowable, nonendoscopic capsule device combined with a biomarker is an acceptable alternative to endoscopy.
- In patients who undergo endoscopic surveillance of BE, both white light endoscopy and chromoendoscopy is recommended.
- Length of BE segment should be considered when surveillance intervals are assigned, with longer intervals reserved for segments less than 3 cm.
- To reduce the risk for progression to high-grade dysplasia or EAC among patients with BE and low-grade dysplasia, endoscopic eradication therapy is recommended vs. close endoscopic surveillance.
- An endoscopic surveillance program is recommended for patients with BE who have completed successful endoscopic eradication therapy.
“This revised guideline synthesizes current best practices in the management of BE, with several key changes since the last iteration that reflect our evolving knowledge base,” Shaheen and colleagues concluded. “We can anticipate continued refinement of quality metrics to ensure optimal strategies for diagnosis, surveillance and therapy of BE.”
Perspective
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Prashanthi N. Thota, MD, FACG
As available evidence continues to evolve, the most recent ACG guidelines provide clear-cut, updated recommendations on the diagnosis and management of patients with BE. Previous guidelines, which included diagnostic criteria for BE (1 cm or greater columnar mucosa with intestinal metaplasia), use of Seattle protocol for surveillance, confirmation of dysplasia by a second pathologist, use of proton pump inhibitor therapy in all patients with BE and endoscopic therapy in BE-associated neoplasia remain unchanged.
The recent guidelines are broadly divided into five categories: diagnosis, screening, surveillance, medical therapy and endoscopic therapy. Some important updates include discussion of alternative technologies, such as confocal laser endomicroscopy and volumetric laser endomicroscopy, multiplex biomarker assays, wide-area transepithelial sampling with computer-assisted 3-dimensional (WATS-3D) analysis and use of quality indicators in management of BE.
Overall, these updated guidelines provide clear data and valuable practical tips on the optimal management of patients with BE.
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