QuestionSBA
QuestionChoice
There is no role for oesophagectomy in Barrett's. Oesophagectomy is a treatment option for oesophageal carcinoma
32426
d
Referral to the multi-disciplinary team (MDT) for consideration of an oesophagectomy
QuestionChoice
RFA is a treatment option for Barrett's with high-grade dysplasia as there is a more significant risk of progressing to cancer
32425
c
Radiofrequency ablation (RFA)
QuestionChoice
High dose PPI alone should be combined with regular surveillance endoscopies to monitor for the development of dysplasia and adenocarcinoma
32427
e
High dose PPI
QuestionChoice
The histological appearances are consistent with a diagnosis of Barrett's oesophagus. This is usually a consequence of long-standing reflux disease and describes the abnormal, reversible change of the oesophageal epithelium from stratified squamous to simple columnar. The major risk factor of Barretts's is oesophageal adenocarcinoma. Treatment is with high dose PPI and regular endoscopies to screen for the development of dysplasia and adenocarcinoma
32423
a
High dose proton-pump inhibitor (PPI) and surveillance endoscopies
QuestionChoice
EMR is a treatment option for Barrett's with high-grade dysplasia as there is a more significant risk of progressing to cancer
32424
b
Endoscopic mucosal resection (EMR)
Concept
Chapter
# Summary

Barrett's oesophagus is a condition seen in patients with long standing gastro-oesophageal reflux disease (GORD). It describes when chronic acid exposure leads to a _change in the distal oesophagus from the usual squamous epithelium to metaplastic columnar epithelium_, known as metaplasia, and this usually occurs in the distal third of the oesophagus. This condition increases risk of oesophageal adenocarcinoma 100-fold which is why monitoring and prompt management is vital.

# Definition

Barrett's oesophagus is defined as an oesophagus in which any part of the distal squamous epithelial lining has been replaced by metaplastic columnar epithelium, visible endoscopically (≥1 cm) above the gastro-oesophageal junction and confirmed histopathologically (e.g. from a biopsy). It is classified according to the degree of dysplasia.


# Epidemiology

Primarily affecting males over 50 with longstanding GORD, the condition has become increasingly prevalent in the UK due to several factors including rising obesity rates and the ageing population. It is thought that about 1 in 20 people who have recurring acid reflux eventually develops Barrett's oesophagus. The risk is mainly in people who have had severe acid reflux for many years.


# Aetiology

The main risk factor for developing Barrett's oesophagus is longstanding **GORD**, however, other risk factors include:

* Obesity
* Smoking
* Hiatus hernia 
* Increasing age (peak incidence 50-70 years)

# Signs and Symptoms

These are the same as those in GORD:

* Pain in the upper abdomen and chest
* Heartburn 
* Acid taste in the mouth
* Bloating
* Belching

Presence of 'ALARM' signs and symptoms (anaemia, loss of weight, anorexia, recent onset/progressive symptoms, melaena) may suggest progression to adenocarcinoma.

# Investigations
- OGD is the gold-standard for diagnosing and classifying Barret's oesophagus

### 2-week-wait referral criteria

- If there is dysphagia or, in those aged 55 years and over with weight loss and any of the following: upper abdominal pain, reflux, or dyspepsia.
- Consider non-urgent direct access upper gastrointestinal endoscopy to assess for oesophageal cancer in people with haematemesis.

# Management

Symptoms should be managed as per GORD management. Further management of Barrett's oesophagus specifically can be categorised into either surveillance or ablation, depending on the classification.

- If there is short-segment (less than 3 cm) Barrett's oesophagus without intestinal metaplasia then no further surveillance is required

## Endoscopic surveillance

- In long-segment (3 cm or longer) Barrett's oesophagus, there should be a repeat OGD every 2 to 3 years 
- In short-segment (less than 3 cm) Barrett's oesophagus with intestinal metaplasia this should be done every 3 to 5 years
- Patients with indefinite dysplasia should have surveillance every 6 months

## Ablation

Patients with **dysplasia** are eligible for ablation therapy, of which there are two techniques of equal efficacy: endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD).

- First-line management of patients with visible high-grade dysplasia is endoscopic ablation of visualised lesions
- These patients should be followed up with endoscopic surveillance, with endoscopic ablation of any residual Barrett's oesophagus offered 


# Complications

It is an important condition to identify as it carries a risk of progression to **oesophageal adenocarcinoma**.

The risk of developing Barrett's oesophagus increases with the length and severity of reflux symptoms.

# NICE Guidelines

[Barrett's oesophagus and stage 1 oesophageal adenocarcinoma: monitoring and management](https://www.nice.org.uk/guidance/ng231/chapter/Recommendations)

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Barrett's oesophagus is characterized by metaplastic changes in the oesophageal lining resulting from chronic gastro-oesophageal reflux disease, requiring PPI therapy and regular surveillance.
A 60-year-old man is referred for an outpatient gastroscopy following worsening reflux symptoms over the last six months.

Gastrosopcy shows a red, velvety appearance of the oesophageal mucosa and biopsies from this region show "metaplastic columnar epithelium replacing the oesophageal squamous epithelium". There are no areas of dysplasia identified.

Which of the following is the best step in management?
a