Barrett’s Oesophagus Surveillance

Barrett’s oesophagus is a premalignant condition where normal squamous epithelium is replaced by columnar epithelium due to chronic reflux.

It increases the risk of:
👉 oesophageal adenocarcinoma

But:

The absolute cancer risk is low for most patients.

So the goal of surveillance is:

  • detect dysplasia early
  • treat high-risk changes
  • avoid unnecessary scopes in low-risk patients

This guide focuses on who needs surveillance, how often, and when to escalate.

✅ First principle

Always ask:

Is there dysplasia or not?

Because:

  • No dysplasia → routine surveillance
  • Dysplasia → specialist pathway

Dysplasia changes everything.

✅ Step 1 – Understand what the report means

Typical endoscopy report:

“Barrett’s C2M5, no dysplasia”

Prague classification:

  • C = circumferential length
  • M = maximum length

Longer segments → higher cancer risk → closer follow-up

You don’t need to memorise numbers — just know:
👉 longer = higher risk

✅ Step 2 – Surveillance intervals (the part juniors need to know)

Keep it simple.

🟢 No dysplasia

Short segment (<3 cm)

👉 OGD every 5 years

Long segment (≥3 cm)

👉 OGD every 3 years

Most patients fall here.

Routine outpatient surveillance only.

🟡 Indefinite for dysplasia

(Inflammation makes histology unclear)

👉 Optimise PPI
👉 Repeat OGD in 6–12 months

Don’t ignore — but not urgent cancer pathway either.

🔴 Low-grade dysplasia (LGD)

Higher cancer risk.

👉 Refer to specialist Barrett’s service

Usually:

  • Confirm by expert pathologist
  • Consider endoscopic ablation therapy
    OR
  • 6–12 month surveillance

This is NOT routine 3–5 yearly follow-up.

Needs gastro input.

🔴 High-grade dysplasia (HGD)

Pre-cancer.

👉 Urgent specialist referral

Usually treated with:

  • Endoscopic mucosal resection (EMR)
  • Radiofrequency ablation

Not surveillance.

This is active treatment.

🔴 Visible lesion or suspicious ulcer

👉 Urgent referral

Treat like possible cancer until proven otherwise.

✅ Step 3 – Who does NOT need surveillance?

Very important in real life.

Don’t scope everyone forever.

Consider stopping if:

  • Frail
  • Elderly
  • Limited life expectancy
  • Significant comorbidities

Because:
Cancer risk is slow and low.

Balance benefit vs risk.

✅ Step 4 – Medical management (what juniors should do)

All Barrett’s patients should usually have:

PPI therapy

  • reduces reflux
  • reduces progression risk

Lifestyle advice

  • weight loss
  • smoking cessation
  • reduce alcohol
  • head-of-bed elevation

This matters more than frequent scopes.

✅ Practical ward/clinic thinking

Scenario 1

Barrett’s 2 cm, no dysplasia
→ repeat in 5 years

Scenario 2

Barrett’s 6 cm, no dysplasia
→ repeat in 3 years

Scenario 3

Low-grade dysplasia reported
→ refer to specialist Barrett’s team

Scenario 4

High-grade dysplasia
→ urgent treatment pathway, not routine surveillance

Scenario 5

85-year-old frail patient
→ may not benefit from surveillance

✅ What juniors should actually check in clinic letters

When reviewing notes:

Look for:

  • Segment length
  • Dysplasia or not
  • Last endoscopy date
  • Planned interval

If unclear → ask gastro team

Don’t guess intervals.

❌ Common junior mistakes

  • Scoping too frequently
  • Treating all Barrett’s as high risk
  • Ignoring dysplasia
  • Forgetting to refer LGD/HGD
  • Continuing surveillance in very frail patients
  • Not prescribing PPI

Remember:
Most Barrett’s patients never develop cancer.

✅ Simple rule to remember

Think:

  • No dysplasia → 3–5 years
  • Any dysplasia → specialist referral
  • Visible lesion → urgent
  • Frail → reconsider surveillance

That’s 95% of decisions.

✅ Take-home concept

Barrett’s without dysplasia is low risk and needs infrequent surveillance.
Dysplasia is the real danger — refer early.
Don’t over-scope low-risk or frail patients.