Gastroenterology

Gastroenterology

Volume 127, Issue 1, July 2004, Pages 310-330
Gastroenterology

Special reports and reviews
A critical review of the diagnosis and management of Barrett’s esophagus: the AGA Chicago Workshop1

https://doi.org/10.1053/j.gastro.2004.04.010Get rights and content

Abstract

Background & Aims: The diagnosis and management of Barrett’s esophagus (BE) are controversial. We conducted a critical review of the literature in BE to provide guidance on clinically relevant issues. Methods: A multidisciplinary group of 18 participants evaluated the strength and the grade of evidence for 42 statements pertaining to the diagnosis, screening, surveillance, and treatment of BE. Each member anonymously voted to accept or reject statements based on the strength of evidence and his own expert opinion. Results: There was strong consensus on most statements for acceptance or rejection. Members rejected statements that screening for BE has been shown to improve mortality from adenocarcinoma or to be cost-effective. Contrary to published clinical guidelines, they did not feel that screening should be recommended for adults over age 50, regardless of age or duration of heartburn. Members were divided on whether surveillance prolongs survival, although the majority agreed that it detects curable neoplasia and can be cost-effective in selected patients. The majority did not feel that acid-reduction therapy reduces the risk of esophageal adenocarcinoma but did agree that nonsteroidal antiinflammatory drugs are associated with a cancer risk reduction and are of promising (but unproven) value. Participants rejected the notion that mucosal ablation with acid suppression prevents adenocarcinoma in BE but agreed that this may be an appropriate strategy in a subgroup of patients with high-grade dysplasia. Conclusions: Based on this review of BE, the opinions of workshop members on issues pertaining to screening and surveillance are at variance with published clinical guidelines.

Section snippets

Workshop methodology

The workshop format was modeled closely after the “Genval” evidence-based appraisal of gastroesophageal reflux disease.5 The workshop comprised 18 physicians (15 gastroenterologists, 2 surgeons, 1 pathologist) from 4 countries. All participants had an established basic or clinical research interest in the epidemiology, diagnosis, or treatment of BE and/or expertise in an evidence-based review process. The material was divided into 4 content areas, each with a designated leader: definition and

Barrett’s esophagus: definition and diagnosis

The definition of BE has evolved over the last 3 decades. Suggested definitions have included the direct observation of “extensive columnar metaplasia” in 19756; a combination of endoscopic, histologic, and manometric criteria in 19877; and, more recently, a combination of endoscopic and histologic criteria consisting of an abnormal appearing distal esophageal lining (endoscopic BE) with histologic evidence of esophageal intestinal metaplasia (confirmed/histologic BE).4 An optimal, practical

Barrett’s esophagus: screening

The goal of a screening program should be to detect neoplasia or lesions at risk of developing neoplasia, allowing intervention or surveillance that leads to improved outcomes such as a reduced incidence of cancer or cancer deaths. Recent guidelines in support of screening for BE4 have been endorsed by other gastrointestinal societies and are commonly followed in clinical practice. However, others disagree with these guidelines because they do not address important issues such as who, when,

Barrett’s esophagus: surveillance

Endoscopic surveillance for patients with BE is recommended to identify curable neoplasia and is based on a number of assumptions: (1) In the absence of surveillance, patients with BE have decreased survival because of deaths from esophageal adenocarcinoma; (2) surveillance of patients with BE reliably detects curable neoplasia (dysplasia or early cancer); and (3) treatment of esophageal neoplasia detected by surveillance prolongs survival. There is scant evidence that BE decreases survival,

Barrett’s esophagus: treatment

Reflux esophagitis often is severe in patients with BE, especially those with longer segments. Once- to twice-daily proton pump inhibitor (PPI) therapy is effective in the treatment of reflux-induced symptoms and esophagitis in BE patients, but there is a lack of systematic research of the optimal use of PPI therapy.150 It is hypothesized that normalization of esophageal acid exposure by intensive PPI will reduce progression to high-grade dysplasia or adenocarcinoma by removal of mucosal

Summary

The workshop addressed 42 statements that deal with controversial areas pertaining to the management of BE. For each statement, evidence supporting or refuting the statement was reviewed and graded by a group of experts. This working group voted unanimously to accept or reject these statements based on the strength of available evidence. It was not the intention of this working group to develop “consensus guidelines” for management of BE. Rather, the group wished to evaluate the strength of

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  • Cited by (0)

    1

    Members of the workshop composed a group of international experts in BE from gastroenterology, surgery, pathology, molecular biology, outcomes, and epidemiology. Conference chairman: Prateek Sharma; conference moderator: Kenneth McQuaid; group leaders: John Dent, M. Brian Fennerty, Richard Sampliner, Stuart Spechler; participants: Alan Cameron, Douglas Corley, Gary Falk, John Goldblum, John Hunter, Janusz Jankowski, Lars Lundell, Brian Reid, Nicholas Shaheen, Amnon Sonnenberg, Kenneth Wang, and Wilfred Weinstein.

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