Management Strategies for Barrett’s Esophagus
According to Dr. P. Sharma: “The current practice of endoscopic surveillance in patients with Barrett’s esophagus has limitations. Biopsies are performed randomly and sample only 4% to 6% of the surface area of the metaplastic epithelium.”
Some believe surveillance is time consuming, and find other methods for sampling the esophagus. This could be just samples of the most visible areas around the GE junction, or random samples in the Barrett's field. A recent study found that only 48.3% of the biopsies were adequate.
In some cases, endoscopically normal appearing squamous tissue may grow on top of Barrett's lining. When this occurs, the Barrett's lining is not only still there, but looks like normal squamous lining through the endoscope. This can lead one to think that the Barrett's is gone when it is simply buried beneath normal appearing squamous lining. This is often referred to as SSIM (subsquamous intestinal metaplasia) or buried glands. Squamous over Barrett's can be found in patients on PPI therapy alone.
A biopsy of the human esophagus takes place at the depth of the lamina propria/muscularis mucosa layer, as illustrated in the preceding figure. The depth is adequate for tissue acquisition to send to pathology, but there are some issues to consider. Biopsies are inconsistent in terms of where they are obtained along the esophagus.
Sampling error refers to a situation where pathology exists, but is missed because the clinician did not choose that area to sample. You can endoscopically see Intestinal Metaplasia (IM), but there may be an advanced grade of Barrett’s in an area that was not sampled. There is a risk that surveillance biopsy may have missed tissue with a more severe diagnosis.