ASGE Masterclass: GERD, Barrett’s Esophagus, and Esophageal Adenocarcinoma

Maximizing esophageal endoscopy entails the following: understanding the indication for the procedure, ensuring adequate sedation, identifying and measuring all landmarks when not over-inflated, using standardized reporting systems (eg, LA grade, Prague classification, Hill grade), evaluating for mucosal abnormalities and targeting biopsies, retroflexing with adequate inspection of the gastroesophageal junction from below, and examining for gastric inlet patches upon withdrawal.

In evaluating gastroesophageal reflux disease (GERD), esophagogastroduodenoscopy (EGD) can assist in confirming GERD. Other ways to evaluate for GERD include pH monitoring with or without impedance, which can give information on non-acid reflux. High-resolution esophageal manometry and EndoFLIP are other modalities that can be used to rule out other diseases, such as dysmotility or achalasia, but they cannot be used for ruling in GERD.

PPIs have been shown to achieve good mucosal healing of damage due to acid exposure, compared with H2-blockers. Increasing the frequency of the PPI to twice-daily dosing significantly improves symptoms, with little to no long-term side effects. Aside from lifestyle modifications, and aside from PPIs and H2-blockers, medications for GERD include prokinetic agents, baclofen for transient lower esophageal sphincter relaxation, and new potassium acid channel blockers.

If GERD is refractory, with incomplete response to medical management, there are surgical options. Fundoplication can be complete or partial, has the best data for regurgitation symptoms, long-segment Barrett’s esophagus refractory to ablation, and lung transplant patients. Roux-en-Y can be considered for obese patients or patients with absent esophageal peristalsis. The LINX system reduces the need for PPIs but, compared with fundoplication, has a higher rate of removal and lower patient satisfaction. Endoscopic treatments for refractory GERD are transoral incisionless fundoplication, which has the best evidence among endoscopic treatments, and the Stretta procedure, which decreases transient lower esophageal sphincter relaxation. Two other endoscopic treatments that create strictures at the gastric cardia are anti-reflux mucosectomy and anti-reflux mucosal ablation.

There are different types of esophageal strictures, and treatment depends on the underlying pathology. Peptic strictures due to acid exposure are treated with full-dose PPI and, if refractory, consideration should be given to adding an H2-blocker, dilating, injecting a steroid, or consulting surgery. Schatzki’s rings may be due to acid exposure, and PPIs can reduce recurrence after dilation. Eosinophilic esophagitis should be treated with drugs (PPIs, steroids), diet, or dilation. Strictures can occur after endotherapy of Barrett’s esophagus (BE). Steroid injection or fully covered self-expanding metal stents can be used prophylactically, or aggressive dilation can be done should strictures form. Stents for benign strictures can be used, but migration rates are high. In complex esophageal strictures, consideration might be given to rendezvous via percutaneous endoscopic gastrostomy, endoscopic stricturoplasty, or self-dilation.

Screening for BE can ultimately reduce esophageal adenocarcinoma (EAC) risk; however, only 10% of patients with BE are screened. Non-EGD screening methods are being studied: EsophaCap, Cytosponge, EsoCheck, and exhaled volatile organic compounds. BE can be diagnosed with endoscopic visualization, with biopsy showing intestinal metaplasia. Advanced techniques can help identify and quantify the BE surface area, including artificial intelligence, optical electronic chromoendoscopy, confocal endomicroscopy, and others. In patients with BE, dysplasia detection is difficult due to noncompliance with surveillance guidelines, interobserver variability among pathologists, and subtle lesions, leading to missed dysplasia and EAC. Wide-area tissue sampling is a method to increase the yield of finding dysplasia and EAC. Prediction tools are available, such as Progression in Barrett's esophagus score, p53 mutation, and TissueCypher assay.

If high-grade dysplasia or EAC up to T1a is detected, resection is required for accurate histologic staging. Resection options are cap-assisted endoscopic mucosal resection (EMR), band-ligation EMR, and endoscopic submucosal dissection. Ablation of residual Barrett’s tissue, such as radiofrequency ablation, cryotherapy, or hybrid argon plasma coagulation, is done after resection to decrease the risk of metachronous dysplasia/neoplasia, resulting in lower rates of esophagectomy. After ablation, surveillance is critical as recurrence can be high.

Use of quality indicators is important in BE screening, detecting BE-related dysplasia, and treating BE with dysplasia/neoplasia, as it will result in better health outcomes and improve the ability to track and report performance.

ASGE GI LEAP URL LINK TO GERD MASTERCLASS