Quality in Barrett's Esophagus: Diagnosis and Management

The field of Barrett's esophagus has been flourishing with major advances in quality clinical practices and technological innovations in both diagnosis and treatment. Gaps in the current screening practices have the potential to be addressed with novel nonendoscopic screening platforms. The foundation for diagnosis and detection in Barrett's esophagus is a high-quality endoscopic examination. These exam components can be summarized as the 5 L's: to identify and document Landmarks, measure and document Length of the Barrett's segment; to Look for subtle irregularities with careful inspection; to document and target visible Lesions; and finally assess each Level of Barrett's segment for occult or subtle dysplastic abnormalities using a protocol such as Seattle protocol. Key tools in endoscopic surveillance are a high-resolution endoscope and either chromoendoscopy with acetic acid or virtual chromoendoscopy. Available adjunctive techniques for detection include other enhanced endoscopic imaging, wide area transepithelial sampling, and tissue-based biomarkers, and artificial intelligence is just on the horizon. Endoscopic eradication therapy is now positioned as the standard strategy for high grade dysplasia and intramucosal carcinoma in Barrett's esophagus in an organ sparing approach. Selected patients with confirmed low-grade dysplasia may also benefit from treatment. Tissue acquiring approaches include endoscopic mucosal resection and endoscopic submucosal dissection. Nontissue acquiring modalities include radiofrequency ablation, cryotherapy, and hybrid APC. This comprehensive review details best practices for diagnosis and treatment in Barrett's esophagus and highlights innovations that are poised for the clinical arena.