Synopsis
Explain Barrett oesophagus risk accurately, deliver evidence-based surveillance and route dysplasia to expert endoscopic therapy without overtreating non-dysplastic disease.
- Barrett oesophagus is endoscopically visible columnar-lined distal oesophagus confirmed histologically; document the gastro-oesophageal junction and circumferential and maximal extent consistently.
- It increases oesophageal adenocarcinoma risk, but the absolute annual risk for an individual with non-dysplastic Barrett is low and should be explained without alarmism.
- Surveillance aims to detect dysplasia or early cancer when endoscopic cure is possible; it is not a guarantee against cancer.
- NICE recommends high-resolution white-light endoscopy with targeted inspection and Seattle-protocol biopsies when surveillance is appropriate.
- For non-dysplastic Barrett, current NICE intervals are every two to three years for segments at least 3 cm and every three to five years for shorter segments with intestinal metaplasia.
- Age, comorbidity, procedural fitness, segment length and patient preference determine whether surveillance benefit outweighs burden.
- Inflammation can mimic dysplasia; optimise reflux control and obtain expert gastrointestinal pathology review before an irreversible treatment decision.
- Visible lesions are characterised and generally resected endoscopically for accurate staging before ablation of remaining dysplastic Barrett mucosa.
- NICE recommends radiofrequency ablation for low-grade dysplasia confirmed from biopsies at two separate endoscopies under the specified pathway.
- Do not offer aspirin solely to prevent Barrett progression; prescribe it only for a separate evidence-based cardiovascular or other indication.
Key red flags
Expert pathology confirms low-grade change and the finding persists on the required separate endoscopic sampling, substantially increasing progression risk and prompting specialist ablation discussion.
Marked architectural and cytological abnormality or T1a cancer requires prompt expert endoscopic staging and treatment, usually including resection of visible lesions.
A nodule, ulcer, depression, irregular mucosa or focal distortion within Barrett should be described and directed to expert endoscopic resection rather than sampled repeatedly without a plan.
Progressive dysphagia, weight loss, bleeding or persistent vomiting overrides the calendar interval and triggers urgent diagnostic endoscopy or cancer assessment.
Investigation priorities
Define landmarks, segment length, inflammation and visible neoplasia.
Management branches
Columnar mucosa is reported at an index endoscopy.
- Verify endoscopic landmarks, measured segment length and histological metaplasia, distinguishing true Barrett from an irregular Z-line or gastric-cardia sampling.
- Review dysplasia through expert pathology where present and ensure active inflammation or a visible lesion has not made the baseline examination unreliable.
- Discuss absolute risk, potential benefit, procedural burden, age, comorbidity and whether the person could undergo treatment if dysplasia were found.
- If surveillance is chosen, set the NICE interval from segment length and histology and provide alarm-symptom safety-netting that overrides the scheduled date.