Barrett Esophagus Rapid Evidence Review - AAFP 2022
Barrett Esophagus Rapid Evidence Review - AAFP 2022
Barrett Esophagus Rapid Evidence Review - AAFP 2022
Carl Bryce, MD;Merima Bucaj, DO;and Renee Gazda, DO, Abrazo Family Medicine Residency, Phoenix, Arizona
Barrett esophagus is a premalignant change of the esophagus;however, malignant transformation to esophageal adeno-
carcinoma is rare in patients without dysplasia. Barrett esophagus is estimated to affect up to 5.6% of the U.S. population.
Risk factors for Barrett esophagus include gastroesophageal reflux disease, obesity, age older than 50 years, male sex,
tobacco use, and a family history of Barrett esophagus or esophageal adeno-
carcinoma. Patients who experience chronic gastroesophageal reflux symptoms
plus additional risk factors should be considered for screening. Mucosal change
consistent with Barrett esophagus is visualized during upper endoscopy;biopsy
confirms the diagnosis and determines if dysplasia is present. Management of
Barrett esophagus depends on the presence and severity of dysplasia;endo-
scopic treatment of dysplasia decreases the risk of malignant transformation.
Surveillance after diagnosis is recommended to monitor for dysplasia and diag-
nose and treat esophageal adenocarcinoma at an earlier stage. Patients with
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BARRETT ESOPHAGUS
BEST PRACTICES IN GASTROENTEROLOGY
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FIGURE 1
Surveillance
• Screening and surveillance are of uncertain
benefit to most patients. Barrett esophagus Barrett esophagus present: proton
• Surveillance leads to detection of earlier-stage not present; no fur- pump inhibitor sufficient to control
esophageal adenocarcinoma but does not lower ther screening for GERD symptoms; consider aspirin and
Barrett esophagus statin if indicated for other condition
all-cause mortality after adjusting for lead-time
bias.26
• Figure 1 summarizes an approach to the
screening, diagnosis, and management of Bar- Barrett esophagus Barrett esophagus and Barrett esophagus and
rett esophagus, which is recommended by expert without dysplasia low-grade dysplasia high-grade dysplasia or
intramucosal carcinoma
societies.19,27
• There is no expert consensus on a safe age to Surveillance endos-
discontinue surveillance, but cost-effectiveness copy every 3 to 5 years;
modeling suggests stopping surveillance of non- manage dysplasia if
Diagnosis confirmed by expert
diagnosed
dysplastic Barrett esophagus for men and women gastrointestinal pathologist
without comorbidities after ages 81 and 75 years,
respectively.28
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BARRETT ESOPHAGUS
SORT:KEY RECOMMENDATIONS FOR PRACTICE
Evidence
Clinical recommendation rating Comments
Consider screening for Barrett esophagus in C Expert opinion and per- patient-years, respectively;
men with GERD symptoms and risk factors for formance analyses of P = .29).37
Barrett esophagus, rather than those with GERD prediction tools on patients
symptoms only. Consider screening women referred for endoscopy Prognosis
only if they have multiple risk factors.19,21,27
• Investigators followed
Treat patients diagnosed with Barrett esophagus B Case-control and cohort 4,207 patients with Bar-
with a proton pump inhibitor daily;intensify to studies and expert opinion rett esophagus for 24,959
twice daily if needed to suppress symptoms of
GERD. 19,27,29 patient-years;of 921 deaths,
64 (7%) were due to fatal
Do not routinely prescribe statins, aspirin, or C Expert opinion in the esophageal adenocarci-
nonsteroidal anti-inflammatory drugs as anti- absence of clinical trials
noma, whereas 857 (93%)
neoplastic therapy for Barrett esophagus unless
a separate indication exists for their use.19,27,32 were due to other causes.38
• The mean life expectancy
GERD = gastroesophageal reflux disease.
following a diagnosis of Bar-
A = consistent, good-quality patient-oriented evidence;B = inconsistent or limited-quality patient-oriented rett esophagus is 22 years;
evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For
information about the SORT evidence rating system, go to https://w ww.aafp.org/afpsort. the lifetime risk of requiring
intervention for high-grade
dysplasia or esophageal ade-
their potential benefits and may also not be cost-effective for nocarcinoma is between one in five and one in six patients.39
the treatment of all patients with Barrett esophagus without • Patients with Barrett esophagus do not seem to be at an
another indication.32 increased risk of all-cause mortality compared with the
general population.40
PROCEDURAL THERAPY
This article updates previous articles on this topic by Zimmer-
• Endoscopic resection, radiofrequency ablation, and man41 and Shalauta and Saad.42
cryoablation can be used to remove or ablate discrete lesions
or dysplasia of Barrett esophagus. Data Sources:A search of Essential Evidence Plus, the Cochrane
database, recently published InfoPOEMs, and PubMed was
• Endoscopic therapies for all patients with Barrett esopha- conducted using the Clinical Queries database for the term
gus without dysplasia are cost-prohibitive and unnecessary.33 Barrett esophagus. Search dates:November 2020, August 2021,
• Endoscopic ablation for low-grade dysplasia reduces December 2021, and April 2022.
the absolute risk of progression to high-grade dysplasia
or esophageal adenocarcinoma by 10.9% (95% CI, 7.2% to
The Authors
14.8%), with an NNT of 10 (95% CI, 7 to 14).34
• Because of the low rate of progression to high-grade CARL BRYCE, MD, FAAFP, is the associate program director at
dysplasia or esophageal adenocarcinoma, surveillance or the Abrazo Family Medicine Residency, Phoenix, Ariz.
endoscopic therapy for Barrett esophagus with low-grade MERIMA BUCAJ, DO, FAAFP, is the program director at the
dysplasia are reasonable options, based on expert opinion Abrazo Family Medicine Residency.
and cost-effectiveness modeling.19,33
• Endoscopic radiofrequency ablation for high-grade dys- RENEE GAZDA, DO, FAAFP, is a core faculty member at the
Abrazo Family Medicine Residency.
plasia compared with a control group reduced the likeli-
hood of esophageal cancer (2% vs. 19%; P = .04; NNT = 7) Address correspondence to Carl Bryce, MD, FAAFP, Abrazo
in one small, randomized trial and is cost-effective and safer Family Medicine Residency, 2000 W. Bethany Home Rd., Ste.
than surgical therapy.33,34 200, Phoenix, AZ 85015 (email:carl.bryce@abrazohealth.
com). Reprints are not available from the authors.
• Adverse effects of radiofrequency ablation include esoph-
ageal stricture (6%), bleeding (1%), and perforation (0.6%).35
• Nodular lesions are removed by endoscopic resection for References
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386 American Family Physician www.aafp.org/afp Volume 106, Number 4 ◆ October 2022
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BARRETT ESOPHAGUS
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