During endoscopy, your doctor will get multiple biopsies every 1 to 2 cm (one half to one inch) along the length of your Barrett’s esophagus segment. How the biopsies look on a microscope slide influences your management.

The key to the management of Barrett’s esophagus is the level of dysplasia that the biopsies show. “Dysplasia” is how much precancerous changes the cells have. “No Dysplasia” means that the Barrett’s cells show no precancerous changes. Low-grade dysplasia means that the cells show some of the early characteristics of cancer. High-grade dysplasia means that the cells show more advanced changes of cancer. The worse the dysplasia, the higher the risk that the Barrett’s will go on to cancer.

All of our cells are programmed to die. We are constantly making new cells while old cells slough off. For example, dandruff is old dead scalp cells that have dried up and flaked off. Just like your skin on the outside of your body, the lining of the esophagus is skin on the inside of your body. Cells keep their DNA in their nucleus. Cancer is DNA that has lost control of how fast the cells divide, or how quickly they die. In cancer, cells grow and grow without dying.

When cells are changing from normal to cancer, they go through the steps of dysplasia outlined above.

No Dysplasia
If a diagnosis of Barrett’s esophagus is made, ideally there should be NO dysplasia. See Cartoon 4 and Figure 2.

Cartoon 4	Figure 2
	No Dysplasia. © 2004 Mayo Foundation for Medical Education and Research.

In biopsies with no dysplasia, the nuclei are small, organized and located at the base (bottom) of the Barrett’s cell.

Most people with Barrett’s esophagus and no dysplasia will need to undergo future endoscopies to assure there is no progression of the condition. When the next endoscopy occurs is usually based on recommendations by groups of experts whose opinion is endorsed The American College of Gastroenterology. Follow up endoscopy for Barrett’s without dysplasia is usually recommended at 3-5 years, but your doctor will help decide what is most appropriate for you.

Low Grade Dysplasia
If biopsies are found to have low-grade dysplasia (Cartoon 5 and Figure 3), where the nuclei are still small but somewhat disorganized, several things should happen: First, the doctor should have a second pathologist also look at your biopsies, because low-grade dysplasia can be a hard diagnosis for a pathologist to make correctly, and sometimes there is disagreement among pathologists that might require yet another opinion to resolve.

Cartoon 5	Figure 3
	Low Grade Dysplasia. © 2004 Mayo Foundation for Medical Education and Research.

If the diagnosis of low-grade dysplasia is confirmed, it is recommended that otherwise healthy people consider getting endoscopic treatment to get rid of their Barrett’s esophagus. The most common way of doing this is a process called radiofrequency ablation. In radiofrequency ablation treatments, heat is applied to the precancerous tissue to kill those cells so that normal healthy cells can grow there instead. Studies demonstrate that these treatments can lower the patient’s chance of ever getting cancer. Another acceptable option if low-grade dysplasia is found is to continue to perform endoscopies to monitor the condition, without doing any ablation treatments. If this option is selected, the repeat endoscopy is usually performed 1 year after the first one.

High Grade Dysplasia
High-grade dysplasia (Cartoon 7, Figure 5) is thought to be the stage that occurs before esophageal cancer. However high-grade dysplasia can regress to low-grade dysplasia. If diagnosed with high-grade dysplasia the biopsies should be examined again by a pathologist who specializes in diseases of the esophagus.

Cartoon 7	Figure 5
	High Grade Dysplasia. © 2004 Mayo Foundation for Medical Education and Research.

If a diagnosis of high-grade dysplasia is confirmed, it is recommended that the patient undergo endoscopic treatments to get rid of the Barrett’s esophagus. As above, the most commonly used treatment in high-grade dysplasia is radiofrequency ablation. Surgical removal of the esophagus can also be performed for high-grade dysplasia; however, this is done more rarely now that effective endoscopic treatments are available.

Barrett’s esophagus is best managed by doctors with an interest in this disease, including gastroenterologists, esophagus surgeons and gastroenterology pathologists.

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