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

Abstract 

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. 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. 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. 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.

Abbreviations:  AB, Alcian blue, BE, Barrett’s esophagus, CK, cytokeratin, GEJ, gastroesophageal junction, LSBE, long-segment BE, PPI, proton pump inhibitor, SSBE, short-segment BE

• 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.