Experts urge risk-based monitoring as Barrett’s esophagus care moves beyond one-size-fits-all

(Press-News.org) Bethesda, MD (Oct. 17, 2025) — The American Gastroenterological Association (AGA) today released a new clinical practice guideline on the surveillance of Barrett's esophagus, the only known precursor to esophageal cancer (adenocarcinoma), a highly lethal cancer whose incidence has risen substantially over recent decades. The guideline provides eight evidence-based recommendations and several key implementation statements to help clinicians monitor patients after a diagnosis of Barrett's esophagus, a condition associated with chronic gastroesophageal reflux disease (GERD).  

"What's novel here is our move away from a one-size-fits-all approach," said guideline author Sachin Wani, MD, AGAF. "We focus on risk stratification and doing endoscopy right — because quality drives earlier detection of neoplasia and better outcomes."  

The guideline emphasizes the need for regular monitoring in many patients with Barrett's esophagus who do not exhibit dysplasia or cancerous changes, while noting situations where monitoring isn't necessary (such as very small segments measuring less than 1 cm). It also provides clear recommendations on when monitoring can be safely stopped, considering age, overall health, and potential benefits. 

For patients who merit surveillance, AGA strongly recommends using high-definition white-light endoscopy in combination with chromoendoscopy to improve detection of Barrett's-related neoplasia, paired with structured sampling protocols and expert pathology review of abnormal cells, called neoplasia. The panel also suggests daily proton pump inhibitor (PPI) therapy as the preferred preventive strategy over no PPI therapy and over anti-reflux surgery. Key implementation statements have focused on tailoring surveillance intervals based on the length of the Barrett's segment, and surveillance strategies for patients with Barrett's esophagus diagnosed with indefinite dysplasia or low-grade dysplasia. 

To address emerging but still evolving technologies, the guideline makes no recommendation for or against the routine use of advanced sampling techniques or biomarkers. Instead, it provides practical guidance for clinicians who choose to use these tests, while highlighting ongoing studies that will define their future role. This document highlights the overall limitations in existing literature and knowledge gaps in the evidence base to guide future research endeavors. 

"We believe these are exciting technologies that will, in the future, significantly impact how we manage patients with Barrett's esophagus," said guideline author Perica Davitkov, MD. "Our guideline provides, for the first time, direction on how these tools might be applied in both community and academic centers. Several ongoing high-quality studies will further define the role of these advanced techniques in risk stratification and in detecting Barrett's-related neoplasia."  

Patients with Barrett's esophagus-related dysplasia or cancer should be referred to specialized centers for management. The guideline panel does not expect any impacts on cost or access, as chromoendoscopy is already integrated into modern endoscopic systems and PPIs are widely available. Training and implementation remain essential to ensure that the benefits of these recommendations are realized in practice.  

Key guideline recommendations:  

In patients with nondysplastic Barrett's esophagus, AGA suggests performing endoscopic surveillance compared with no surveillance.   In patients with columnar-lined esophagus <1 centimeter with intestinal metaplasia without neoplasia, AGA suggests against endoscopic surveillance.

In patients undergoing surveillance endoscopy for Barrett's esophagus, AGA recommends using a combination of high-definition white light endoscopy plus chromoendoscopy compared with white light endoscopy alone.  

In patients undergoing surveillance endoscopy for Barrett's esophagus, AGA makes no recommendation for or against the use of wide-area transepithelial sampling as an adjunctive sampling technique to a structured biopsy protocol.  

In patients diagnosed with nondysplastic Barrett's esophagus, Barrett's esophagus with indefinite for dysplasia, or Barrett's esophagus with low-grade dysplasia, AGA makes no recommendation for or against the routine use of p53 assessment as an adjunct test to histopathology to predict progression to high-grade dysplasia or esophageal adenocarcinoma.

In patients diagnosed with nondysplastic Barrett's esophagus, Barrett's esophagus with indefinite for dysplasia, or Barrett's esophagus with low-grade dysplasia, AGA makes no recommendation for or against the routine use of Tissue Cypher testing as an adjunct test to histopathology.  

In adult patients with Barrett's esophagus, AGA suggests the use of daily PPI therapy compared with no PPI therapy for the prevention of neoplastic progression of Barrett's esophagus. 

In patients with Barrett's esophagus, AGA suggests the use of PPIs over surgery for the prevention of neoplastic progression to high-grade dysplasia or esophageal adenocarcinoma.  

This guideline is the second installment in AGA's updated three-part series on Barrett's esophagus, following the 2024 guideline on endoscopic eradication therapy, with a third guideline on screening expected in 2026.

Understanding Barrett's esophagus 
Barrett's esophagus is a change to the lining of the esophagus (the tube connecting your mouth to your stomach). These changes happen in a small number of patients with chronic gastroesophageal reflux disease (GERD). Barrett's esophagus is a change in the type of cell that occurs in the esophagus and does not typically cause any symptoms. Over time, there can be changes within the cells (dysplasia) that increase the risk of developing one type of cancer in the esophagus called adenocarcinoma.  

GERD is common, but most people with GERD do not get Barrett's esophagus. Tobacco use and being overweight are important risks for developing Barrett's esophagus. Most people with Barrett's esophagus do not get cancer, but because the risk is higher than for people without Barrett's esophagus, it is recommended to monitor for changes over time.  

Learn more in the AGA GI Patient Center.  

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AGA Media Contact: Annie Mehl, Communications and Media Relations Manager, media@gastro.org, 301-327-0013  

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The American Gastroenterological Association is the trusted voice of the GI community. Founded in 1897, AGA represents members from around the globe who are involved in all aspects of the science, practice, and advancement of gastroenterology. The AGA Institute administers the practice, research, and educational programs of the organization. www.gastro.org  

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About Gastroenterology 
Gastroenterology is the most prominent journal in the field of gastrointestinal disease. As the official journal of the AGA Institute, Gastroenterology delivers up-to-date and authoritative coverage of both basic and clinical gastroenterology. Regular features include articles by leading authorities and reports on the latest treatments for diseases. Original research is organized by clinical and basic-translational content, as well as by alimentary tract, liver, pancreas, and biliary content. www.gastrojournal.org/ 

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