Low-grade esophageal dysplasia must be confirmed by a GI pathologist with a special interest in Barrett’s esophagus, one who deals with the problem on a daily basis and whom peers recognize as an expert in the field, according to a new expert review from the American Gastroenterological Association (Gastroenterology. doi: http://dx.doi.org/10.1053/j.gastro.2016.09.040).
In the absence of reliable biomarkers, it’s the best guarantee that low-grade dysplasia (LGD) is truly present. Overdiagnosis of early dysplasia is common, and it leads to mistreatment and uncertainty about study results, the AGA said.
Dr. Sachin Wani
In the absence of reliable biomarkers, AGA turned to expertise to combat mistreatment. Although it’s clear that high-grade disease and esophageal adenocarcinoma need intervention, LGD sometimes seems to regress on its own, but it’s unclear if it’s due to natural history or diagnosis in patients who don’t really have it.
For now, expertise is the best solution. “Unfortunately, there is no database that clearly identifies experts in the field of Barrett’s esophagus,” but most practitioners can identify people to “refer these patients to within their state or region.” Meanwhile, “we are working tirelessly” to establish a referral and outcome database. “We owe it to” patients to let them know “how good the” people we are referring them to are, Dr. Wani said.
Given the diagnosis uncertainty, AGA side-stepped the biggest controversy in LGD: whether patients should be treated or watched. Among “patients with confirmed Barrett’s esophagus with LGD by expert GI pathology review that persists on a [second] endoscopy despite intensification of acid-suppressive therapy” at 8-12 weeks with proton pump inhibitors twice a day, “risks and benefits of management options of endoscopic eradication therapy (specifically adverse events associated with endoscopic resection and ablation) and ongoing surveillance should be discussed and documented,” the group said.
When patients opt for treatment, endoscopic eradication should proceed “with the goal of achieving complete eradication of intestinal metaplasia ... radiofrequency ablation should be used,” AGA said.
Meanwhile, “patients with LGD undergoing surveillance rather than endoscopic eradication therapy should undergo surveillance every 6 months times two, then annually unless there is reversion to nondysplastic Barrett’s esophagus. Biopsies should be obtained in 4-quadrants every 1-2 cm and of any visible lesions.”
AGA funded the work. Dr. Wani is a Medtronic and Boston Scientific consultant.