Barrett's oesophagus

Overview

Barrett's oesophagus (columnar metaplasia of the distal oesophagus) can result as a complication of gastro-oesophageal reflux disease and has malignant potential and an increased risk of developing oesophageal adenocarcinoma(1).

Cancer Risk

• The annual risk for patients with long segment disease (more than 3 cm of the distal oesophagus involved) is 1% (1)
• Overall, the absolute annual risk of patients with Barrett’s oesophagus (short and long segment dieease) developing oesophageal adenocarcinoma is ≤ 0.5% (2).
• The lifetime risk is ~10% (3). 

Who to Refer

Patients without known Barrett's oesophagus

Patients with alarm symptoms should be referred for endoscopy appropriately (see Red flag section below).

Patients with GORD without alarm symptoms should be managed according to the Dyspepsia and Reflux guidelines and should be referred for upper GI endoscopy when inidicated.

BSG guidelines (2013) (5) state that endoscopic screening is not feasible or justified for an unselected population with GORD but endoscopic screening can be considered in patients with chronic GORD symptoms (>15yrs) and at least three of:

• Age ≥50 years
• White race
• Male sex
• Obesity

The threshold for screening should be lowered if positive family history of at least one first degree relative with Barrett's or Oesophageal adenocarcinoma.

Barrett's surveillance

Patients with previously diagnosed Barrett's oesophagus should be placed on a recall register with their endoscopy provider if this is indicated and following a shared decision with the patient based on their risk, age, sex, family history of oesophageal cancer and smoking history (4).

There are NICE guidelines (4) on recommended frequency of endoscopic surviellance.

If there are delays in undertaking surveillance then please direct patient to contact their provider in the first instance (see ''Services' section at bottom of the page for details).

If a patient has moved to the area or has been lost to follow up then please refer as below, providing a copy of the patient’s past OGD report and histology if at all possible:

• Patients with known Barrett's who present with alarm symptoms - refer via 2WW upper GI pathway.
• Patients with Long segment disease  (> or = 3cm) should be referred to the local hospital outpatient department via eRS (not for direct access endoscopy) due to their higher risk of dysplasia which may not be suitable for follow up in community services.
• Patients with Short segment disease  (< 3cm)  should be referred to a direct access endoscopy service using the standard BNNSG endoscopy referral form following a discussion of risk (unless exclusions apply, in which case refer to local outpatient department via eRS)- see also Referral section below. 

Patients with Barrett's diagnosed in a direct access service and found to have a segment > or = 3cm where the provider does not offer follow up,  will need to be referred onwards by their GP to a secondary care service via eRS for ongoing surviellance (i.e. AQP providers cannot refer directly into secondary care).

Endoscopic surveillance should not be offered to people with short-segment (< 3 cm) Barrett's oesophagus without intestinal metaplasia provided the diagnosis has been confirmed at 2 endoscopies (4).

Shared Decision Making and Barrett's Surveillance

Not all patients with Barrett's oesphagus need surveillance (i.e. short segment, no intestinal metaplasia with no other red flags) and some patients will choose not to - for example in patients who are aged over 80 and/or are frail or have significant comorbidities. A shared decision approach should be made with the patient before deciding to refer in these cases.

If uncertainty exists about need for follow up then please refer to the community GI clinic or to gastroenterology outpatients via eRS, for discussion about ongoing surveillance.

Red Flags

Red flags include:

• Upper abdominal mass

• Dysphagia

• Age 55 or over with weight loss and one or more of the following: upper abdominal pain, reflux, dyspepsia.

Please see Upper GI - USC (2WW) guidelines for further information

What to do before referral

When referring for surveillance, it is advisable to provide information about a patient's suitability for endoscopy including details of comorbidities. Please also include recent pathology results such as FBC, UE, LFT if they are relevant (although they are not routinely required).

Please also provide a copy of the patient’s past OGD report and histology if possible and particularly if a patient  is being referred having moved to the area.

Services

Please see the endoscopy page for details of providers of endoscopy across BNSSG.

UHBW Service

At UHBW, the Barrett's service is the managed by the Oesophago-gastric (OG) surgical team. If they have completed the index OGD, they will arrange the follow up OGD. They will write to the patient with results and confirm surveillance interval. If you are concerned someone has been lost to surveillance please contact the OG surgical team and they can follow up.

New referrals can be directed by letter to the Upper GI surgery team via eRS.

NBT Service

At NBT, the endoscopy department undertakes Barrett's surveillance. They do not offer any therapeutic interventions at Southmead for Barrett’s. Please refer to UHBW upper GI surgery (as above) if therapeutic interventions need consideration.

New or lost to follow up patients can be directed by letter to the gastroenterology team via eRS who will triage appropriately.

Community Diagnostic Centre - Community Diagnostic Centres (Remedy BNSSG ICB)

The CDC run by InHealth endoscopy provide a community endoscopy service including Barrett's surveillance.

Short Segment Barrett's - The CDC  will follow up patients with short segment Barrett’s (Circumferential (C) Barretts < 3cm) if indicated.

New referrals should be made using the BNSSG endoscopy proforma via eRS.

Long Segment Barrett's - Patients found to have  Circumferential (C) Barrett’s > or = 3cm will be advised to have subsequent follow up in secondary care and will be returned to their GP to facilitate this. 

If unsure then GPs can reach out to discuss on a case by case basis with InHealth via email: primeendoscopy.bristol@nhs.net

(1) Complications | Background information | Dyspepsia - proven GORD | CKS | NICE

(2) Barrett’s Oesophagus Surveillance versus endoscopy at need Study (BOSS): protocol and analysis plan for a multicentre randomized controlled trial. Old et al. J Med Screen. 2015, Vol. 22(3) 158–164).

(3) Gatenby, Piers, Christine Caygill, Christine Wall, Santanu Bhatacharjee, James Ramus, Anthony Watson, and Marc Winslet. “Lifetime Risk of Esophageal Adenocarcinoma in Patients with Barrett’s Esophagus.” World Journal of Gastroenterology : WJG 20, no. 28 (July 28, 2014): 9611–17. https://doi.org/10.3748/wjg.v20.i28.9611

(4) Overview | Barrett's oesophagus and stage 1 oesophageal adenocarcinoma: monitoring and management | Guidance | NICE

(5) BSG guidelines on the diagnosis and management of Barrett's oesophagus - The British Society of Gastroenterology 

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