Clinical

Chronic management

Barrett's Oesophagus

Background

  • Barrett’s oesophagus describes a change to the lining of the gullet (columnar metaplasia) which can in some cases lead to the development of oesophageal cancer (adenocarcinoma).
  • Most members of the public are not aware of the link between obesity and carcinoma of the oesophagus. At a national and local level, publicity and education should be employed to correct this.
  • Alcohol consumption increases the risk of some types of oesophageal cancer. There are many reasons to reduce alcohol consumption. If this were achieved it would reduce the incidence of this cancer.
  • The public should be vigilant to signs such new indigestion or difficult swallowing
  • The incidence of oesophageal cancer in the UK is one of the highest in the world, such that it is more common than gastric cancer. Smoking, alchohol and obesity are major risk factors, and for 2/3rd of patients, BO is the precursor lesion. However the relationship between GORD, BO and subsequent cancer is unclear.

Patient View

  • Most patients are diagnosed with BO because they had heartburn and were referred to a specialist. Many patients on surveillance programmes are not fully aware of the risk /benefits of surveillance.
  • The incidence of OC shows a north /south divide and is related to social deprivation.

Current Practice

Upper GI endoscopy and biopsy remain the gold standard for diagnosis.

  • Long term follow-up for high risk BO with appropriate endoscopic imaging should be delivered by tertiary level super specialists centres
  • High dose PPIs and anti-reflux surgery for underlying symptoms of GORD maybe helpful, but awaiting outcomes of BOSS trial to determine if any reduction in cancer.
  • Current surveillance of BO is not supported by robust evidence base and much clinical practice falls below best recommended. Audit has shown that many patients under surveillance have significant co-morbidity which either causes death or prevents curative surgical intervention.

Opportunities for Integrated Working

  • Evidence suggests that establishing a valid disease register specific for Barrett’s oesophagus with dedicated endoscopists performing surveillance according to strict protocols results in an better adherence to the planned surveillance interval (increased from 17% to 92%) and improvement in the collection of sufficient biopsies (increased from 45% to 83%).

Opportunities for Savings

  • Current surveillance strategies are of limited value, and it may be appropriate to restrict surveillance to young patients with additional risk factors such as stricture, ulcer, or long segment (>80 mm) Barrett's oesophagus and no significant co-morbidity.

Quality Indicators / Outcome Measures

  • Barrett’s surveillance should be only be done in centres meeting QA standards for best practice.
  • Surveillance centres should provide evidence of networked research to inform future practice, especially for stratifying risk and targeting surveillance in Barrett's oesophagus
  • Rates of oesophageal cancer development in patients under surveillance
  • Longterm cure rates of BO for patients after radio frequency ablation

Social Policy & Understanding

  • It is clear that Barrett’s Oesophagus can regress with treatments such as Endoscopic Radio frequency ablation may cure Barrett’s, but currently subject to NICE guidance and restricted to patients with BO and dysplasia.
  • Small pre-malignant and malignant lesions can be removed endoscopically
  • Robust methods for stratifying risk and targeting surveillance in Barrett's oesophagus are needed.

References

  • British Society of Gastroenterology (2005) Guidelines for the diagnosis and management of Barrett’s columnar-lined oesophagus: http://www.bsg.org.uk/images/stories/docs/clinical/guidelines/oesophageal/Barretts_Oes.pdf
  • NICE Clinical Guidelines (2010) – Barrett’s oesophagus – ablative therapy: www.nice.org.uk/guidance/CG106