Endoscopic Treatment of Barrett’s Esophagus Flashcards
What characterizes Barrett’s esophagus (BE)?
gradual replacement of the normal stratified squamous epithelium of the esophagus with columnar, intestinal metaplasia.
What is the primary risk factor for Barrett’s esophagus (BE)?
Longstanding gastroesophageal reflux disease (GERD)
Besides GERD, what are other risk factors for BE?
Male sex
age over 50 years
central obesity
White Race
Smoking
Family Hx
What are risk factors for progression of BE to dysplasia?
Increasing age and long-segment BE (> 3 cm).
How does the risk of progression to EAC change in patients with low-grade dysplasia (LGD)?
The risk increases to 0.5% per year.
What is the risk of progression to EAC for patients with high-grade dysplasia (HGD)?
Up to 19% in some studies.
What criteria does the American College of Gastroenterology (ACG) recommend for screening for BE or EAC?
Screening is recommended for male patients with 5 or more years of GERD symptoms and two or more risk factors
(age > 50 years, white race, central obesity, smoking history, family history of BE or EAC)
What is the gold standard for diagnosing Barrett’s esophagus?
High-resolution endoscopy with narrow band imaging and biopsy.
What are the Prague Criteria used to measure in Barrett’s esophagus?
The extent of disease based on circumference (C) and maximum length (M), with C being the Max circumferential extent and M the Max length extent including any isolated tongues of disease
What is the current recommendation for evaluating patients with BE for dysplasia or invasive cancer?
High-resolution or high-definition white light endoscopy with careful inspection of the esophageal lumen, including a retroflexed view of the gastroesophageal junction
What is the recommended approach for sampling lesions during endoscopy in BE?
Suspicious lesions
(erosions, ulcerations, nodules, plaques) should be selectively sampled
while random biopsies are not recommended.
What is the recommendation for taking biopsies in patients with active, erosive esophagitis?
Avoid biopsies and treat the patient with antisecretory agents until the inflammation subsides
How often should patients with Barrett’s esophagus without dysplasia undergo repeat endoscopic surveillance?
Every 3 to 5 years.
What is the protocol for patients with inconclusive biopsies for dysplasia?
Place them on an acid suppression regimen for 3 to 6 months, followed by repeat endoscopy.
If still inconclusive, perform another endoscopy 12 months later.
What is recommended when dysplasia is diagnosed in Barrett’s esophagus?
Biopsies should be reviewed by two pathologists, one of whom is an expert in gastrointestinal pathology.
What is the preferred treatment for low-grade dysplasia (LGD) in Barrett’s esophagus
Endoscopic therapy is preferred for patients without significant comorbidity
although repeat endoscopy in 12 months is acceptable
What is the recommended treatment for high-grade dysplasia (HGD) in Barrett’s esophagus?
Endoscopic therapy, unless the patient has life-limiting comorbidities.
When should surgery be considered for patients with Barrett’s esophagus?
young patients with long-segment multifocal HGD
recurrent HGD
or intramucosal cancer
Management of Non nodular barrett’s
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Management of nodular Barrett’s esophagus
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For which conditions in Barrett’s esophagus (BE) is endoscopic therapy recommended?
low-grade dysplasia (LGD)
high-grade dysplasia (HGD)
early intramucosal esophageal adenocarcinoma (T1a EAC)
Why is endoscopic therapy preferred for patients with LGD, HGD, and early intramucosal EAC?
Because the risk of lymph node metastasis is nonexistent for LGD and HGD and low for intramucosal EAC
What does the American College of Gastroenterology (ACG) recommend as the initial treatment for nodular BE?
EMR is recommended as the initial treatment modality
What is the eradication rate of Barrett’s esophagus (BE) in patients without high-risk features after EMR?
98.8% eradication rate.
What is the eradication rate of Barrett’s esophagus (BE) in patients with high-risk features after EMR?
80.6% eradication rate.
What is the eradication rate of T1a tumors using EMR?
91% to 98%.
Methods of EMR
Cap-assisted method
ligation-assisted method
What is one of the primary side effects of EMR, and how is it managed?
Esophageal stricture, occurring in up to 40% of patients, is typically managed with endoscopic dilation or stents.
What are the risks associated with EMR alone?
A 33.5% risk of stricture, 7.5% risk of bleeding, and 1.3% risk of perforation.
How do the risks of EMR compare when used in conjunction with radiofrequency ablation (RFA)?
In combination with RFA, the risks are lower: 10.2% for stricture, 1.1% for bleeding, and 0.2% for perforation
What is endoscopic submucosal dissection (ESD) primarily used for in Barrett’s esophagus?
ESD allows for en bloc resection of suspicious lesions, providing thorough histologic evaluation, especially for larger lesions (> 1.5–2 cm).
How does ESD compare to EMR in terms of lesion resection?
ESD allows for complete resection of lesions in one piece, while EMR often requires piecemeal resection, especially for larger lesions
What is the primary indication for performing ESD?
Resection of nodular lesions within a segment of Barrett’s esophagus for complete histologic evaluation.
What is the general technique involved in ESD?
The area of resection is marked with coagulation, the submucosal space is injected with saline to lift the area, and resection knives are used to incise the mucosa and perform the submucosal dissection.
What were the results of a recent multicenter study on ESD performed in the United States?
En bloc resection occurred in 95.7% of patients.
R0 resection was achieved in 76.1%.
Overall cure rate was 69.6%.
Adverse events occurred in 23.9% of patients
What were the adverse events associated with ESD in the multicenter study?
Bleeding (6.5%)
Perforation (2.2%)
Esophageal stricture (15.2%) All adverse events were managed endoscopically
What are the two most widely available photosensitizing agents used in PDT?
Photofrin and 5-aminolevulinic acid.
What are some common complications associated with photodynamic therapy (PDT)?
Cutaneous photosensitivity in more than two-thirds of patients
Odynophagia
Constipation
Vomiting
Noncardiac chest pain
Dehydration
Dysphagia
Stricture formation (up to 36% in some studies)
Why is PDT no longer widely used for Barrett’s esophagus?
Due to its relatively high complication rate.
How deep is the necrosis caused by argon plasma coagulation (APC)?
The depth of necrosis is relatively shallow, around 2–3 mm.
What is the most widely studied cryotherapy system for treating Barrett’s esophagus?
Liquid nitrogen.
What is one advantage of cryotherapy in the treatment of Barrett’s esophagus?
Cryotherapy can be used as both a first-line treatment for BE with dysplasia and a second-line treatment for patients who failed other therapies
What were the complication rates in a recent review of liquid nitrogen cryotherapy?
10% of patients experienced pain requiring narcotics.
What is the most commonly used ablative technique for Barrett’s esophagus (BE)?
Radiofrequency ablation (RFA).
How does radiofrequency ablation (RFA) work?
A generator and a bipolar electrode array deliver thermal energy, creating a uniform burn to a depth of 0.5 mm, either via a balloon catheter (circumferential ablation) or a focal catheter (focal ablation).
When is circumferential RFA versus focal RFA used?
Circumferential RFA: For BE segments longer than 2 cm.
Focal RFA: For shorter segments or tongues of BE
What is the follow-up recommendation after RFA treatment for Barrett’s esophagus?
Follow-up is recommended approximately 2 months after treatment, with multiple sessions often required to achieve complete eradication of dysplasia
What are the primary side effects of radiofrequency ablation (RFA)?
Chest pain and dysphagia lasting up to 4 days, with strictures occurring in up to 8% of patients
For which type of Barrett’s esophagus is RFA the preferred therapy?
RFA is the preferred therapy for nonnodular BE.
