There have been lots of discussions on the online support group about a new diagnosis and surveillance, so I thought I’d highlight some of the key points from the NEW National Institute for Health and Care Excellence (NICE) Guidance.  I have also tried to explain about how the condition is diagnosed and included some information on the terms you may come across when you receive a Barrett's diagnosis.

Short v long segment

This is based on an endoscopy and what the endoscopist sees and measures.

As discussed on our online Facebook support group, short is (less than) <3cm and long is (more than) >3 cm. This refers to the M figure.

The classification, known as PRAGUE classification, is then divided into C and M.  M is the total length of the Barrett’s include any tongues. C is how much in centimetres is all around the oesophagus. So M6C3 would have a total length of 6cm but it would only be all round for 3cm.

Biopsy

The way to properly diagnose Barrett’s with dysplasia or metaplasia is by biopsy. The Cytosponge can also diagnose dysplasia but you still need an endoscopy to fully assess the extent and confirm diagnosis.

Errors

There is always room for error. What is seen can vary depending on the endoscopist. Where the biopsies are taken they can miss abnormalities. Pathologists can differ in their interpretation of biopsies. This is true in many areas of medicine and is difficult to completely prevent.

Guidelines

When I was working as a GP, I liked prescriptive guidelines to follow. GPs cannot be experts on everything. Having easy access to guidelines, knowing what I should do and what I should expect the hospital to do made my life easy. I liked guidelines like the cancer ones that also include the recommendation that if a GP is worried and explains why, they can refer outside the guidelines and expect the hospital to take the referral seriously.

The NICE guidelines are aimed at providing advice for both Healthcare Professionals and adults (and their families and carers) and could be used to have a useful discussion with your GP or hospital. Below are some of the key points that I feel may be helpful to people to know and enable patients to work out how they compare to the care they are being offered. 

1.1 Information and support

• 1.1.1 Offer a clinical consultation to people with newly diagnosed Barrett's oesophagus to discuss risk of cancer, endoscopic surveillance plans and symptom control.
• 1.1.2 Give the person verbal and written information about their diagnosis, available treatments and patient support groups. Give them time to consider this information when making decisions about their care.
• 1.1.3 After each surveillance procedure, provide the person with an endoscopy report that includes a lay summary of the findings and a reference to ongoing symptom control.

1.3 Endoscopic surveillance

• 1.3.1 Discuss the benefits and risks of endoscopic surveillance with the person diagnosed with Barrett's oesophagus.
• 1.3.2 Offer high resolution white light endoscopy with Seattle biopsy protocol for surveillance of Barrett's oesophagus. Take into account the health of the person and ensure the benefits of surveillance outweigh the risks.

Frequency of endoscopic surveillance

• 1.3.3 Offer high resolution white light endoscopic surveillance with Seattle protocol biopsies:
• every 2 to 3 years to people with long-segment (3 cm or longer) Barrett's oesophagus.
• every 3 to 5 years to people with short-segment (less than 3 cm) Barrett's oesophagus with intestinal metaplasia.
• 1.3.4 Assess a person's risk of cancer based on their age, sex, family history of oesophageal cancer and smoking history and tailor the frequency of endoscopic surveillance accordingly, within the intervals given in recommendation 1.3.3.

1.5 Managing Barrett's oesophagus with dysplasia

• 1.5.1 Offer endoscopic resection of visible oesophageal lesions as first-line treatment to people with high-grade dysplasia.
• 1.5.2 Offer endoscopic ablation of any residual Barrett's oesophagus to people with high-grade dysplasia after treatment with endoscopic resection.
• 1.5.3 Offer radiofrequency ablation to people with low-grade oesophageal dysplasia diagnosed from biopsies taken at 2 separate endoscopies. Two gastrointestinal pathologists should confirm the histological diagnosis.
• 1.5.4 Consider endoscopic surveillance at 6 monthly intervals with dose optimisation of acid-suppressant medication for people diagnosed with indefinite dysplasia of the oesophagus.
• 1.5.5 Offer endoscopic follow-up to people who have received endoscopic treatment for Barrett's oesophagus with dysplasia.
• 1.5.6 Follow the NICE interventional procedures guidance on endoscopic radiofrequency ablation for Barrett's oesophagus with low-grade dysplasia or no dysplasia and epithelial radiofrequency ablation for Barrett's oesophagus.

I had hoped they would cover the issue of detecting Barrett’s in the first place this is still covered by old NICE guidance from 2014 last updated 2019.

The relevant paragraph is still as below:

1.6.11 Do not routinely offer endoscopy to diagnose Barrett's oesophagus, but consider it if the person has GORD. Discuss the person's preferences and their individual risk factors (for example, long duration of symptoms, increased frequency of symptoms, previous oesophagitis, previous hiatus hernia, oesophageal stricture or oesophageal ulcers, or male gender). [new 2014]

I would interpret as being an option for anyone with GORD.

I hope this blog summarises the salient points which I hope will aid your discussions with medical professionals and, in addition helps to allay any fears you may have of not being followed up properly. 

To view the information for the public click here.