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

Abstract

PREAMBLEThe 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.

Overdiagnosis of high-grade dysplasia in Barrett's esophagus: a multicenter, international study

“…3,4 Barrett's esophagus was defined according to criteria of the American College of Gastroenterology, whereby endoscopic glandular (pink) mucosa within the anatomic tubular esophagus, as well as histological intestinal metaplasia with goblets cells on biopsy histology, were both required. 2 Patients were enrolled from both academic and private centers at 25 study sites from throughout USA, two sites from Canada, two sites from the UK, and one site from France. The original diagnostic slides were reviewed and a repeat protocol endoscopy was performed by an experienced study gastroenterologist on 485 patients presenting for screening, obtaining four-quadrant jumbo biopsies every 2 cm throughout the Barrett's segment and additional biopsies of any visible lesion(s).…”

“…Overdiagnosis of high-grade dysplasia is especially unfortunate considering its aggressive management consequences, including esophagectomy or endoscopic treatment modalities. 2 The magnitude of the overdiagnosis problem has not been systematically evaluated. We sought to examine the prevalence and sources of this problem, based on patients undergoing screening for an endoscopic ablation trial of Barrett's esophagus with high-grade dysplasia.…”

Radiofrequency Ablation of Barrett’s Esophagus: Let’s Not Get Ahead of Ourselves

“…There is universal agreement that high-grade dysplasia poses a major risk for the development of cancer, and current practice guidelines recommend intervention in these patients [7]. Studies to date, including the landmark randomized controlled trial of Shaheen et al (ablation of intestinal metaplasia [AIM] dysplasia trial), demonstrate a clear benefit for RFA in the treatment of high-grade dysplasia, ideally with endoscopic mucosal resection of any mucosal abnormalities prior to application [5,8].…”

Grading of gastric foveolar-type dysplasia in Barrett's esophagus

“…Barrett's esophagus was defined using the American College of Gastroenterology definition, requiring both endoscopic (glandular mucosa in the anatomic tubular esophagus) and histological (intestinal metaplasia with goblet cells) parameters. 8 Using these criteria, a total of 1854 endoscopic biopsies from a cohort of 200 consecutive Barrett's dysplasia patients were selected for the study.…”