WHAT TO DO IF YOU ARE HEALTHY BUT HAVE SERIOUS BARRETTS ESOPHAGITIS

The most appropriate management of a healthy patient with Barrett’s esophagus is nothing --except for regular monitoring by endoscopy.
When and if nodularity or ulceration is discovered in a segment of Barrett’s esophagus, additional targeted biopsies should be obtained due to heightened suspicion for dysplasia or cancer.
The most appropriate management of verified high-grade dysplasia within a nodule is surgical referral, in line with American College of Gastroenterology guidelines. Although the management of expert-verified, high-grade dysplasia (HGD) remains somewhat controversial -- in a relatively young, healthy patient with long-segment Barrett’s esophagus, surgical resection remains the only modality that ensures complete removal of all dysplastic tissue and provides definitive confirmation of the diagnosis (and absence of invasive cancer).
In addition, the entire Barrett’s segment would theoretically be excised, eliminating potential future neoplastic risk.

Other Options:

Endoscopic mucosal resection (EMR) is a reasonable option but should still be considered experimental at this time and reserved for clinical trials, patients at high surgical risk, or for those who decline surgery.
The long Barrett’s segment would remain and continue to require intensive surveillance.
Similarly, photodynamic therapy, argon plasma coagulation, and Nd:YAG laser photoablation would all provide the potential for ablation of the nodular lesion, as well as mucosal reversal of the Barrett’s segment.
But these options would not provide deep-tissue sampling for confirmation of the diagnosis and could leave “buried glands” under the reversed segment.
As with EMR, these modalities should be reserved for research protocols and high risk patients.

References
1. Sampliner, R. Updated guidelines for the diagnosis, surveillance, and therapy of Barrett's esophagus. Am J Gastroenterol. 2002;97:1888.
2. Soetikno, R, Gotoda, T, Nakanishi, Y, et al. Endoscopic mucosal resection. Gastrointest Endosc. 2003;57:567.
3. Scotiniotis, I, Kochman, M, Lewis J, et al. Accuracy of EUS in the evaluation of Barrett's esophagus and high-grade dysplasia or intramucosal carcinoma. Gastrointest Endosc. 2001;54:689.
4. Collard, J. High-grade dysplasia in Barrett's esophagus. The case for esophagectomy. Chest Surg Clin N Am. 2002;12:77.


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