Recent developments in pathogenesis, diagnosis and therapy of Barrett's esophagus

Table 1 Comparison of societal guidelines for screening and surveillance in Barrett’s esophagus

	Screening	Surveillance NDBE	Surveillance LGD	Surveillance HGD
AGA[104]	Screening for patients with multiple risk factors	Recommend surveillance	Low-grade dysplasia: 6-12 mo	High-grade dysplasia in the absence of eradication therapy: 3 mo
	Age 50 yr or older	No dysplasia:
	Male sex	three to five years
	White race
	Chronic GERD
	Hiatal hernia
	Elevated body mass index
	Intra-abdominal distribution of body fat
	Screening in the general population is not recommended
BSG[48]	Endoscopic screening can be considered in patients with chronic GERD symptoms and multiple risk factors (at least three of age 50 yr or older, white race, male sex, obesity)	Patients with Barrett’s oesophagus shorter than 3 cm, with IM, should receive endoscopic surveillance every 3-5 yr	High resolution endoscopy every 6 mo	Not recommended
	The threshold of multiple risk factors should be lowered in the presence of family history including at least one first-degree relative with Barrett’s or OAC	Patients with segments of 3 cm or longer should receive surveillance every 2-3 yr		For HGD and Barrett’s-related adenocarcinoma confined to the mucosa, endoscopic therapy is preferred over esophagectomy or endoscopic surveillance
ASGE[33]	Endoscopic screening for BE can be	Consider no surveillance	Confirm with expert GI pathologist	Confirm with expert GI pathologist
	considered in select patients with multiple risk factors for BE and EAC, but patients should be informed that there is insufficient evidence to affirm that this practice prevents cancer or prolongs life	If surveillance is elected, perform EGD every 3 to 5 years with 4-quadrant biopsies every 2 cm	Repeat EGD in 6 mo to confirm LGD	Consider surveillance EGD every 3 mo in select patients, 4-quadrant biopsies every 1 cm
		Consider endoscopic ablation in select cases	Surveillance EGD every year, 4-quadrant biopsies every 1 to 2 cm	Consider endoscopic resection or RFA ablation
			Consider endoscopic resection or ablation	Consider EUS for local staging and lymphadenopathy
				Consider surgical consultation
ACP[34]	Upper endoscopy may be indicated among men older than 50 yr with chronic GERD symptoms (symptoms for more than 5 yr) and additional risk factors (nocturnal reflux symptoms, hiatal hernia, elevated body mass index, tobacco use, and intra-abdominal distribution of fat) to detect esophageal adenocarcinoma and be	For surveillance evaluation in men and women with a history of be. In men and women with be and no dysplasia, surveillance examinations should occur at intervals no more frequently than 3 to 5 yr. More frequent intervals are indicated in patients with Barrett esophagus and dysplasia

AGA: American Gastroenterology Association; BSG: British Society for Gastroenterology; ASGE: American Society for Gastrointestinal Endoscopy; ACP: American College of Physicians; HGD: High grade dysplasia; GERD: Gastroesophageal reflux; NDBE: Non-dysplastic BE; BE: Barrett’s esophagus; LGD: Low grade dysplasia; EAC: Esophageal adenocarcinoma; RFA: Radiofrequency ablation.

Table 2 Estimated effectiveness and durability of current endotherapies for Barrett’s esophagus

	Radiofrequency ablation with or without EMR[75,77,78,105]	1Cryotherap[79]	Endoscopic mucosal resection[80]	Photo-dynamic therapy[106,107]
Initial eradication of HGD	90%-95%	100%	90%	81%
Initial CRIM	70%-86%	100%	90%	72%
Recurrence of non-dysplastic Barrett’s	13%-33% at 2-3 yr	19% at 36 mo1	39.5% at 5 yr	Unknown
Recurrence of dysplasia or cancer	1.6%-11% at 1.5-2.5 yr	3% at 36 mo	6.2% at 5 yr	16%-20% at 2-5 yr
Adverse events	Stricture 4%-11.9%	Stricture 9%	Stricture 47% (widespread EMR)	Stricture 37%

¹The 37.5% required touch up treatment after initial eradication 19% developed recurrent HDG but were successfully re-treated. Study methods: EMR for focal nodular BE, ablation of flat BE with any modality followed by EMR if ablation failed. CRIM: Complete remission from intestinal metaplasia; EMR: Endoscopic mucosal resection; BE: Barrett’s esophagus; HGD: High grade dysplasia.