Quality Improvement in Gastroenterology Clinical Practice

Rakhi Kheraj; Sumeet K. Tewani; Gyanprakash Ketwaroo; Daniel A. Leffler


Clin Gastroenterol Hepatol. 2012;10(12):1305-1314. 

In This Article

Barrett's Esophagus

In BE metaplastic columnar epithelium, which has a predisposition to cancer, replaces the normal stratified squamous epithelium of the distal esophagus.[59] The change can be of any length, is recognized as columnar mucosa at endoscopy, and is confirmed to have intestinal metaplasia by biopsy. BE is the most important identifiable risk factor for esophageal adenocarcinoma;[60] BE is estimated to affect 0.5%–1.5% of the general population of the United States and 5%–15% of patients with chronic GERD. The key quality issues in BE involve medical therapy, appropriate endoscopic surveillance, and treatment of dysplastic BE.

Pharmacologic acid suppression is recommended for all patients with BE, with the goal of controlling reflux symptoms.[60] Although acid suppression does not appear to prevent esophageal adenocarcinoma, PPI therapy may reduce the risk for dysplasia in patients with BE; this reduction provides the rationale to also treat asymptomatic patients with a PPI.[59] The objective of surveillance endoscopy for patients with BE is to identify and treat dysplasia before it progresses to esophageal adenocarcinoma, although it is not known whether surveillance actually reduces cancer incidence or mortality.[59,60] In the 2011 Medical Position Statement by the AGA, the following recommendations were made (grade B*). Surveillance should be performed by using white-light endoscopy, with 4-quadrant biopsies obtained from every 2 cm of BE. Any mucosal irregularity should be analyzed separately by biopsy, and 4-quadrant biopsies should be collected from every 1 cm in areas of known or suspected dysplasia. Any dysplasia should be confirmed by an expert gastrointestinal pathologist, because the grade of dysplasia determines the appropriate surveillance interval; more advanced disease requires more frequent surveillance, because it has an increased rate of progression to cancer. Patients diagnosed with BE but no dysplasia, which is based on the initial endoscopy examination, should be reexamined by endoscopy and biopsy analysis within 1 year; if the absence of dysplasia is confirmed, further surveillance should not be performed in less than 3 years on the basis of the recommendations from the AGA and ASGE.[59,68] A summary of the appropriate surveillance intervals is beyond the scope of this review.

High-grade dysplasia is the threshold for intervention in patients with BE.[59] Options include intensive surveillance; endoscopic mucosal ablation with photodynamic therapy, radiofrequency ablation (RFA), cryotherapy or thermal ablation therapy, endoscopic mucosal resection (EMR), or esophagectomy. In recent years, RFA and EMR have become the most popular endoscopic approaches and can be safely offered as combination therapy for patients with confirmed high-grade dysplasia at a visible lesion (grade B*).[59] In this case, EMR of the lesion is performed first, followed by RFA of the remaining Barrett's epithelium.[69] After endoscopic ablative therapy or EMR is complete, patients should be maintained on high-dose PPI therapy to allow for healing and regeneration of the neosquamous esophageal epithelium.[69] Follow-up endoscopy should be performed at 8–12 weeks to assess the results of therapy and to consider repeat ablation if residual BE is found. The AGA recommends that patients who have had ablative therapy continue surveillance via biopsy analysis of the entire area where BE was detected at intervals appropriate for the highest pretreatment grade of dysplasia until there is reasonable certainty of complete ablation. Periodic surveillance thereafter is recommended by guidelines from the major societies.[59]

A successful QI initiative for BE could focus on promoting the appropriate endoscopic evaluation of all patients with BE by using 4-quadrant biopsies and making appropriate recommendations for continued surveillance or therapeutic intervention based on the grade of dysplasia identified. (1) Records from patients with BE would be reviewed to ascertain the proportion with each grade of dysplasia and provide recommendations for interval surveillance or treatment. (2) The rate of appropriate surveillance or treatment might be improved by computerized notification when the final pathology report is reviewed. (3) Clinicians could enter the follow-up interval or treatment referral or provide the medical, patient, or system reason(s) for opting out, and a reminder system would recall the patient. (4) Once implemented, prospective assessments can determine whether patients with BE are appropriately recommended for interval surveillance or therapeutic intervention, on the basis of their grade of dysplasia. Imperfections of this trigger and reminder system can be repeatedly evaluated for continued improvement. Similarly, in another QI project a review of all patients seen with BE could be undertaken to ensure that these patients remain on PPI therapy to reduce the risk of dysplasia and also that appropriate steps are taken to reduce the risks associated with long-term PPI therapy.