Barrett's esophagus on repeat endoscopy: should we look more than once?

Barrett's esophagus (BE) is the precursor lesion for esophageal adenocarcinoma. The major risk factor for BE is chronic gastroesophageal reflux disease (GERD). Screening patients with longstanding GERD for BE with upper esophagogastroduodenoscopy (EGD) has become the standard practice, and guidelines from national gastrointestinal (GI) societies recommend only a single screening EGD because of limited evidence, suggesting that BE develops early in the course of GERD. We hypothesized that BE may be present in patients in whom initial endoscopy was negative, either due to a missed diagnosis or due to the later development of BE.

The purpose of the study was to determine how often BE is identified on repeat endoscopy performed after an initial negative examination.

The Clinical Outcomes Research Initiative (CORI) National Endoscopic Database was searched for all patients who had more than one EGD during the 5-yr period between January 1, 2000, and December 31, 2004. Patients who had either procedure for an indication of surveillance of BE were excluded. The primary outcome was a finding of newly suspected BE on repeat examination after an initial negative examination.

In total, 24,406 patients underwent more than one endoscopy during the study period. Five hundred sixty-one (2.3%) were found to have suspected BE on repeat EGD following an initial negative examination. More men than women had BE on repeat examination (3.1%vs 1.2%, P < 0.0001). BE on repeat examination was more common in patients with reflux as an indication for endoscopy than in patients with any other indication (5%vs 1.6%, P< or =0.0001). In reflux patients with esophagitis on initial examination, 9.9% were found to have suspected BE on repeat examination versus 1.8% of reflux patients with no esophagitis on initial examination (P < 0.0001).

BE is rarely found on second endoscopy performed less than 5 yr after an initial negative examination except in patients with esophagitis on the first endoscopy. Repeat EGD for Barrett's screening should not be performed out of concern for a missed diagnosis except when BE may have been obscured by overlying esophageal inflammation.