Barrett's esophagus: current and future management

Barrett's esophagus is considered to be a preneoplastic condition associated with chronic reflux esophagitis. The risk of neoplasia is difficult to assess but appears to be increased by about 40-fold with an incidence of 1:200 patient years. Diagnosis of Barrett's esophagus is made by endoscopy with biopsy of the suspected area. Barrett's is histologically confirmed by the presence of specialized epithelium (intestinal metaplasia). Histologic findings of low-grade dysplasia and high-grade dysplasia have increased neoplastic risks. The development of cancer within a Barrett's esophagus appears to be related to a sequence of molecular events beginning with the loss of the tumor suppressor gene p53 and followed by the loss of the 5q chromosome. Current management of Barrett's esophagus includes controlling reflux esophagitis and following selected patients with surveillance biopsies. Surgical resection has been advocated for patients with high-grade dysplasia, although this has not been proven to be a cost-effective strategy. Prospective management options include long-term omeprazole use, flow cytometry, endosonography, laser-induced fluorescence, photodynamic therapy, and argon laser therapy. However, long-term observation is needed to determine whether these approaches can impact upon cancer development.