Barrett’s oesophagus
Definition:
It’s a metaplastic change in the type of cells lining the lower part of the oesophagus and GOJ from squamous cells to columnar cells. (It’s therefore confirmed histologically)
Prague Classification – how is it measured?
– Check for hiatus hernia
– Check for GOJ
– Length of circumferential spread of Squamous epithelium from GOJ = C
– Length of maximum spread of Squamous epithelium from GOJ = M
What’s the natural history of low-grade dysplasia?
In Barrett’s LGD the architecture is relatively preserved but some atypical changes may be seen in the deeper glands. It’s difficult to be certain due to much inter-observer variation. But its accepted that LGD is associated with increased risk of progression to cancer.
How would you manage high grade dysplasia within Barrett’s?
These specimens should be reviewed by 2 GI pathologists. The patient should be referred to a tertiary centre MDT. If the consensus is that no cancer exists, then it can be considered for EMR.
If removed by EMR and histology confirms there is no invasion, the patients should be considered for RFA (shown to be better than APC or PDT)
How would you mange nodularity in the Barrett’s mucosa?
The concern would be that it’s malignant. Therefore multiple biopsies should be taken in the Seattle Protocol fashion to confirm Barrett’s and at least 6 biopsies taken of the nodularity.
The patient should be started on high does (BD) PPI and re-scoped in 4-6 weeks once the inflammation has settled.
What are the complications of RFA?
10% stricture formation
Bleeding
Perforation
(All patients undergoing RFA are entered into the UK national HALO Patient Registry, 2012)
Is there evidence for ablative therapy in LGD?
Yes. RCTs and NICE guidelines support its use in expert hands. The Surveillance vs RFA study (SURF) was a multi-centre RCT and showed progression to adenocarcinoma was significantly reduced at 3 years. (2% vs 27%)