Screening and surveillance

Screening and surveillance

The risk factors for Barrett’s oesophagus and related neoplasm include chronic (>5 years) GORD symptoms, advanced age (>50 years), smoking, central obesity and male gender. For non-dysplastic Barrett’s, the risk of progression to cancer is around 0.2–0.5% per year. This increases to around 0.7% per year for low-grade dysplasia. For high-grade dysplasia, the risk of cancer progression can be as high as 7%. Therefore, screen ing and surveillance protocols should be tailored to individuals - - according to the potential benefit of cancer prevention and the risk and cost-e ff ectiveness of such intervention ( Figure 66.22 ). Screening or surveillance aims to identify premalignant lesions - and to treat them early .

Figure 66.20 Computed tomography scan showing a large type IV paraoesophageal hernia with stomach and intestine in the mediasti

num and left thoracic cavity. Mediastinal shift towards the right side is evident. Depth of endoscope insertion (cm) 28 Squamocolumnar junction 30 32 Columnar metaplasia 34 Oesophagogastric junction 36 36 Hiatus hernia Stomach Figure 66.21 Prague C&M criteria to report endoscopic Barrett’s oesophagus. The location of the oesophagogastric junction is de /f_i ned by the top of the gastric folds (36 cm). Prague criteria of Barrett’s oesophagus are expressed in C (circumferential), in this case 33–36 /uni00A0 cm (3 cm), and M (maximum extent), in this case 28–36 cm (8 /uni00A0 cm). This patient therefore has Prague C3 M8 Barrett’s oesophagus.

The vast majority of patients with Barrett’s oesophagus in the community are asymptomatic; a general population screening programme is considered not to be cost-e ff ective. High-definition white light endoscopy including NBI is used to assess the mucosal and vascular patterns of the Barrett’s segment. Additional chromoendoscopy using di ff erent agents, e.g. methylene blue, acetic acid or indigo carmine, could aid diagnosis. The histological specimen obtained should be examined by an experienced gastrointestinal pathologist. The sensitivity of the assessment can be improved by increasing the number of biopsies and, w hen in doubt, endoscopy and biopsy should be repeated. The Seattle biopsy protocol, which includes four-quadrant random biopsies every 2 /uni00A0 cm in addi tion to targeted biopsies on macroscopically visible lesions, is recommended at the time of diagnosis and subsequent sur veillance.

Repeat OGD every – 3 5 years No dysplasia Maximum length < 3 cm Maximum length < 3 cm Maximum length Gastric metaplasia Intestinal metaplasia ≥ 3 cm Repeat OGD every Repeat OGD every Repeat OGD 3–5 years 2–3 years Length < 3 cm Gastric metaplasia Consider discharging Figure 66.22 Algorithm for managing Barrett’s oesophagus, including dysplasia. Summary of guidelines from the American College of Gastro enterology (orange) and the British Society of Gastroenterology (blue). BO, Barrett’s oesophagus; HGD, high-grade dysplasia; LGD, low-grade dysplasia; MDT, multidisciplinary team; OAC, oesophageal adenocarcinoma; OGD, oesophagogastroduodenoscopy.