How Should Barrett’s Esophagus Be Monitored for Dysplasia and Cancer?

The goal is cancer prevention without oversurveillance

Barrett’s esophagus is the recognized precursor of esophageal adenocarcinoma, but absolute annual progression risk is low in nondysplastic disease. Surveillance therefore needs adequate detection quality and sensible interval/risk selection rather than simply “more endoscopy.”

Use high-quality imaging and structured inspection

AGA’s 2025 guideline strongly recommends high-definition white-light endoscopy combined with chromoendoscopy rather than white light alone.[1] Careful cleaning, adequate inspection time, landmark documentation and targeted sampling of visible abnormalities are core quality elements.

Biopsy strategy still matters

Visible lesions should be sampled or resected appropriately, and structured biopsy protocols remain important because dysplasia can be subtle or flat. When dysplasia is reported, confirmation by an expert GI pathologist is important because interobserver variability is clinically meaningful.

Very short segments should not be medicalized indefinitely

AGA suggests against surveillance when columnar-lined esophagus is less than 1 cm with intestinal metaplasia and no neoplasia.[1] This is an important deimplementation recommendation that can reduce low-value repeated endoscopy.

PPI therapy is part of the surveillance strategy

The 2025 AGA guideline suggests daily PPI therapy over no PPI and over antireflux surgery for prevention of neoplastic progression.[1] Surgery may still be indicated for reflux control in selected patients, but it is not preferred as a cancer-prevention strategy.

When dysplasia is found

Low-grade and high-grade dysplasia require careful confirmation and discussion of endoscopic eradication therapy. Visible lesions are generally resected before ablation so histology can define depth and risk. Surveillance after eradication remains necessary.

Stopping surveillance

Age, comorbidity, life expectancy and whether the patient could benefit from treatment if neoplasia were found should enter decisions about continuing surveillance. A surveillance program that cannot lead to beneficial intervention has little value.

Questions trainees should be able to answer

• What imaging combination does the 2025 AGA guideline recommend?
• What does the guideline say about <1 cm columnar-lined esophagus?
• Why should dysplasia be confirmed by expert pathology?

Frequently asked questions

Is white-light endoscopy alone enough? AGA 2025 recommends high-definition white-light endoscopy plus chromoendoscopy for surveillance.[1]

Does every patient with intestinal metaplasia need surveillance? No. Very short <1 cm columnar-lined segments without neoplasia should generally not enter surveillance under the 2025 AGA guideline.[1]

Should antireflux surgery be used to prevent cancer? AGA suggests PPI therapy over antireflux surgery for prevention of neoplastic progression.[1]

Free further reading from Dr. Thomson

• Endoscopy and Diagnostic Imaging — free book library
• Guideline-Based Management in Gastroenterology — free book library

References

1. Wani S, Zhou MJ, Sawas T, et al. AGA Clinical Practice Guideline on Surveillance of Barrett’s Esophagus. Gastroenterology. 2025;169. doi:10.1053/j.gastro.2025.09.012.

2. Shaheen NJ, Falk GW, Iyer PG, et al. Diagnosis and Management of Barrett’s Esophagus: An Updated ACG Guideline. Am J Gastroenterol. 2022;117.

3. Thomson ABR. Endoscopy and Diagnostic Imaging. Parts I-II. CAPstone Academic Publishers; 2012.

Educational use only. This article is intended for clinicians and trainees and does not replace patient-specific medical judgment or local guidance.