Screening and surveillance for complications related to gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) and columnar-lined esophagus with intestinal metaplasia (Barrett's esophagus) are the major recognized risk factors for adenocarcinoma of the esophagus. The American College of Gastroenterology recommends that patients with long-standing GERD symptoms (particularly those 50 years of age or older) undergo endoscopic screening to identify Barrett's esophagus and that those patients who have Barrett's esophagus undergo regular endoscopic surveillance. These recommendations are made with the expectation that screening and surveillance will decrease mortality from esophageal cancer, although this association is unclear. Nonetheless, retrospective studies have shown that endoscopic surveillance can detect some early, curable neoplasms in patients with Barrett's esophagus. Dysplasia in Barrett's esophagus is widely regarded as the precursor of invasive malignancy. Although grading dysplastic changes is largely subjective, dysplasia remains the most appropriate biomarker for clinical evaluation of Barrett's esophagus. Flow-cytometric and p53 abnormalities may be earlier and more specific markers for cancer development, but application of these abnormalities is not yet recommended for clinical practice. Endoscopic surveillance also is adversely affected by biopsy sampling error. Techniques that may minimize biopsy sampling error include chromoendoscopy, endosonography, optical coherence tomography, and fluorescence detection techniques. Further studies are needed to clearly define the role of these techniques in surveillance, and none is practical for routine clinical use at this time. Although not specifically recommended, experimental ablative therapies, such as photodynamic therapy, can be considered by physicians for their patients with high-grade dysplasia in Barrett's esophagus, if they are provided as part of an established, approved research protocol.