Non-Dysplastic Barrett's Esophagus

Barrett's esophagus (BE) is a condition in which tissue that is similar to the tissue lining in the intestines changes or replaces the lining of the esophagus (the tube that transports food from the mouth to the stomach).

Even though BE has a chance of progressing into low- or high-grade dysplasia (a precancerous condition) and then transform into cancers of the esophagus, in most cases, the dysplasia may not be presented or cannot be identified by biopsy specimens. Such a condition is termed as non-dysplastic BE.

All patients with non-dysplastic BE are subjected to endoscopic surveillance every two to three years in order to diagnose any prevalent signs for dysplasia. If discovered with such a risk of progression to dysplasia, patients are provided with rigorous treatment.

Clinical Presentation and Risk Factors

Non-dysplastic BE manifests as column-like cells including mucin-filled, blue-tinted goblets. The risk factors of progression from non-dysplastic BE to esophageal cancer may include length of the BE greater than or equal to 6 cm and hiatal hernia of length more than 3 cm. However, progression of non-dysplastic BE to esophageal adenocarcinoma and higher grade dysplasia is really uncommon with the risk accounting for less than 1%.

This grade of non-dysplastic BE, where the tissue begins to change to resemble the red intestinal tissue linings is also referred as Intestinal Metaplasia (IM).

Diagnosis

BE (both with and without dysplasia) is diagnosed by a diagnostic endoscopy, which is performed using very high resolution and white light to view the internal lining of the esophagus. The management therapy and surveillance interval for patients with BE is determined by dysplasia grade.

For non-dysplastic patients with BE, endoscopic surveillance is suggested every three years along with biopsies, as some patients with additional risk factors such as age less than 30 at the time of BE diagnosis and family history of esophageal cancer may promote non-dysplastic BE to cancer. The non-dysplastic BE suspected patient undergoes endoscopy for 6–12 months and biopsies are done each time to determine the cytological and structural changes to the epithelial cells.

New advanced imaging techniques for detecting BE are improved and they include narrowband imaging, chemoendoscopy, optical coherence tomography, and laser confocal microscopy.

Management of Non-Dysplastic BE

For BE without the presence of dysplasia or cancer, the traditional management techniques are used as the common primary approach of treatment. This includes controlling the symptoms of BE and regular endoscopic surveillance to prevent progressive disease. Healthy changes in the lifestyle may help in clearing acid in the esophagus and lessening the prevalence of reflux events. Avoiding certain food such as citrus foods, beverages, spicy and fatty foods, and tomatoes will benefit in controlling the symptoms.

Periodical endoscopies and biopsies must be done to estimate the affected area by Barrett’s disease. Some high-risk patients without dysplasia are recommended with treatment options such as endoscopic mucosal resection and radiofrequency ablation therapy.

• Endoscopic mucosal resection: Patients of BE without dysplasia may primarily undergo endoscopic mucosal resection as an initial diagnostic or treatment step. In this approach, the affected mucosal linings in the esophagus are therapeutically removed using endoscope. The damaged mucosa is resected and lifted using a saline solution and then eliminated by means of a cap or snare accessory. Adjacent and deep margins are examined by proper handling of the sample. In non-dysplastic BE cases, the patients are not subjected to routine endoscopic ablative therapy due to their lower risk of development of esophageal adenocarcinoma.

• Radiofrequency ablation: The non-dysplastic BE in patients is managed by radiofrequency ablation (RFA) therapy. The RFA process involves radiofrequency energy to ablate the damage tissue through endoscopy. Depending on cryotherapy, two methods are available. The first approach includes a liquid nitrogen spray that removes the tissue by freezing it, while the second approach involves a cryoballoon, i.e., a balloon filled with nitrous oxide is placed on the tissue to freeze them.

The RFA therapy is repeated once or thrice to confirm the eradication of the whole affected tissue by BE. In this technique, the risk for bleeding after the procedure is very less and also does not involve any stricture formation. After RFA, initial surveillance is done to ensure complete elimination of BE and no recurrence. It is usually done every three to five years.

The RFA for non-dysplastic BE is cost-effective and has an efficiency upto 90%; however, the periodic surveillance in non-dysplastic BE is quite expensive.

Follow-up

Patients with non-dysplastic BE after ablation therapy should involve follow-up of 4-quadrant biopsy for every 1 or 2 cm of complete area that was previously affected with BE. Endoscopic surveillance should be done on a routine basis initially once in six months in the first year post ablation therapy.