New American Guidelines for Endoscopic Treatment of Barrett's Esophagus

Barrett's Esophagus (BE) is a precursor to esophageal adenocarcinoma (EAC), a type of cancer. The American Gastroenterological Association (AGA) has recently released guidelines on Endoscopic Eradication Therapy (EET) to assist healthcare providers in managing this condition effectively. These guidelines are based on extensive research and input from experts across various prestigious institutions, including the University of Michigan, University of Texas Southwestern, Mayo Clinic, University Hospitals Case Western Reserve University, and the University of San Diego.


Understanding Barrett's Esophagus
Barrett's esophagus occurs when the tissue lining the esophagus changes due to chronic acid reflux. Over time, this condition can lead to complications such as EAC, a serious form of cancer.


What is Endoscopic Eradication Therapy (EET)?
EET involves using advanced endoscopic techniques to remove abnormal tissue and reduce the risk of cancer in patients with Barrett's esophagus. It is recommended in certain cases to prevent progression to more severe stages of the disease.


Key Recommendations by the AGA

High-Grade Dysplasia (HGD)

High-grade dysplasia in Barrett's esophagus is a precancerous condition where the cells lining the esophagus have significant abnormalities. These cells appear very different from normal cells under a microscope and have a high risk of progressing to EAC.
 

• The AGA strongly recommends EET over surveillance for individuals with HGD due to moderate certainty of evidence.
• After EET, regular surveillance should be conducted to monitor for any recurrence or new developments.

Low-Grade Dysplasia (LGD)

Low-grade dysplasia in Barrett's esophagus is a less severe form of cellular abnormality compared to high-grade dysplasia. The cells show some changes from normal, but these changes are less pronounced than in high-grade dysplasia. LGD carries a lower risk of progression to EAC than HGD but still indicates an increased risk compared to non-dysplastic Barrett's esophagus.
 

• The AGA suggests considering EET over surveillance for individuals with LGD, although this recommendation is conditional due to uncertainties about its benefits.
• Surveillance intervals should be adjusted after EET based on initial findings.

Non-Dysplastic Barrett's Esophagus (NDBE)

Non-dysplastic Barrett's esophagus is a condition where the normal cells lining the esophagus are replaced by intestinal-like cells, typically due to chronic gastroesophageal reflux disease (GERD). While these cells are abnormal (intestinal metaplasia), they do not yet show dysplasia, meaning they do not have the cellular abnormalities seen in LGD or HGD. Non-dysplastic Barrett's esophagus still carries a risk of progression to dysplasia and subsequently to EAC, but this risk is lower than in cases with dysplasia.
 

• The AGA advises against routine use of EET for patients with NDBE, citing very low certainty of evidence regarding its effectiveness in this group.

Management of Visible Lesions

Visible lesions in Barrett's esophagus refer to any noticeable abnormalities or irregularities seen during endoscopic examination of the esophagus. These lesions can appear as nodules, ulcers, or raised areas and can indicate areas where dysplasia or early cancer may be present. The identification of visible lesions is important as they may warrant targeted biopsies and more aggressive management.
 

• For patients undergoing EET, the AGA recommends removing visible lesions followed by ablating the remaining Barrett's esophagus segment instead of removing the entire segment.
• Radiofrequency ablation (RFA) is preferred for ablating remaining segments.

Choosing Resection Techniques

• Depending on lesion characteristics, either Endoscopic Mucosal Resection (EMR) or Endoscopic Submucosal Dissection (ESD) may be used for removing visible neoplastic lesions.
• EMR is generally suitable for most cases, while ESD may be considered for more complex lesions.

Bumrungrad International Hospital: Leading the Way in Barrett's Esophagus Treatment
Bumrungrad International Hospital is renowned for its exceptional care and state-of-the-art facilities, making it one of the best places to manage Barrett's esophagus. Here’s why:


Expertise and Experience
Our team of gastroenterologists includes specialists trained in the latest endoscopic techniques, ensuring high-quality care for patients with Barrett's esophagus. With experience in both EMR and ESD, our experts are well-equipped to handle even the most complex cases.


Advanced Technology
We utilize cutting-edge technology, including high-definition endoscopy and radiofrequency ablation, to provide precise and effective treatment. Our facilities are equipped to perform comprehensive diagnostics and therapeutic procedures, ensuring optimal patient outcomes.


Multidisciplinary Approach
At Bumrungrad International Hospital, we believe in a collaborative approach to care. Our multidisciplinary team includes gastroenterologists, pathologists, radiologists, and surgeons, working together to develop personalized treatment plans for each patient.


Patient-Centered Care
We prioritize patient comfort and safety, providing detailed pre-procedure and post-procedure instructions. Our dedicated staff is committed to supporting patients throughout their treatment journey, from initial diagnosis to follow-up care.


International Recognition
Bumrungrad International Hospital is recognized globally for its excellence in healthcare. Our adherence to international standards and guidelines ensures that patients receive the highest level of care available.


Conclusion and Considerations
The new AGA guidelines provide a clear framework for healthcare providers and patients to make informed decisions about managing Barrett's esophagus. Shared decision-making is encouraged to align treatment choices with patient preferences and clinical circumstances.

By following these recommendations and seeking care at Bumrungrad International Hospital, patients can benefit from timely intervention and effective management of this potentially serious condition. Our commitment to excellence and patient-centered care makes us a top choice for individuals with Barrett's esophagus.


Looking Ahead
While these guidelines offer valuable insights, ongoing research is essential to address current limitations and enhance treatment outcomes for individuals with Barrett's esophagus. At Bumrungrad International Hospital, we are dedicated to advancing our understanding and treatment of this condition, ensuring the best possible care for our patients.


by Tossapol Kerdsirichairat, MD, FASGE
Clinical Associate Professor of Medicine
Advanced/Bariatric Endoscopy, Digestive Disease Center
Bumrungrad International Hospital