Special reports and reviewsA critical review of the diagnosis and management of Barrett’s esophagus: the AGA Chicago Workshop1
Section snippets
Workshop methodology
The workshop format was modeled closely after the “Genval” evidence-based appraisal of gastroesophageal reflux disease.5 The workshop comprised 18 physicians (15 gastroenterologists, 2 surgeons, 1 pathologist) from 4 countries. All participants had an established basic or clinical research interest in the epidemiology, diagnosis, or treatment of BE and/or expertise in an evidence-based review process. The material was divided into 4 content areas, each with a designated leader: definition and
Barrett’s esophagus: definition and diagnosis
The definition of BE has evolved over the last 3 decades. Suggested definitions have included the direct observation of “extensive columnar metaplasia” in 19756; a combination of endoscopic, histologic, and manometric criteria in 19877; and, more recently, a combination of endoscopic and histologic criteria consisting of an abnormal appearing distal esophageal lining (endoscopic BE) with histologic evidence of esophageal intestinal metaplasia (confirmed/histologic BE).4 An optimal, practical
Barrett’s esophagus: screening
The goal of a screening program should be to detect neoplasia or lesions at risk of developing neoplasia, allowing intervention or surveillance that leads to improved outcomes such as a reduced incidence of cancer or cancer deaths. Recent guidelines in support of screening for BE4 have been endorsed by other gastrointestinal societies and are commonly followed in clinical practice. However, others disagree with these guidelines because they do not address important issues such as who, when,
Barrett’s esophagus: surveillance
Endoscopic surveillance for patients with BE is recommended to identify curable neoplasia and is based on a number of assumptions: (1) In the absence of surveillance, patients with BE have decreased survival because of deaths from esophageal adenocarcinoma; (2) surveillance of patients with BE reliably detects curable neoplasia (dysplasia or early cancer); and (3) treatment of esophageal neoplasia detected by surveillance prolongs survival. There is scant evidence that BE decreases survival,
Barrett’s esophagus: treatment
Reflux esophagitis often is severe in patients with BE, especially those with longer segments. Once- to twice-daily proton pump inhibitor (PPI) therapy is effective in the treatment of reflux-induced symptoms and esophagitis in BE patients, but there is a lack of systematic research of the optimal use of PPI therapy.150 It is hypothesized that normalization of esophageal acid exposure by intensive PPI will reduce progression to high-grade dysplasia or adenocarcinoma by removal of mucosal
Summary
The workshop addressed 42 statements that deal with controversial areas pertaining to the management of BE. For each statement, evidence supporting or refuting the statement was reviewed and graded by a group of experts. This working group voted unanimously to accept or reject these statements based on the strength of available evidence. It was not the intention of this working group to develop “consensus guidelines” for management of BE. Rather, the group wished to evaluate the strength of
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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.