This ASG video tip is brought to you by an educational grant from Braintree, a part of Cibela Pharmaceuticals, makers of SUTAB. Hi, my name is Keovis Rodian. I'm a gastroenterologist at Columbia University Irving Medical Center. In honor of esophageal cancer awareness month, I'll be presenting this ASG video tip on how to perform a high quality examination for Barrett's esophagus. We'll briefly review some background, then review a mnemonic in more detail that can assist you in performing a high quality Barrett's exam, touch on some emerging quality tools, and then summarize some take home points. Barrett's esophagus is the replacement of pink esophageal squamous epithelium with salmon colored gastric columnar epithelium as shown here on the right. To diagnose Barrett's, you need at least a centimeter of this columnar epithelium, plus a biopsy showing intestinal metaplasia with goblet cells. Barrett's is important because it's the precursor to esophageal adenocarcinoma, or EAC, and it follows a stepwise progression through intestinal metaplasia, low grade dysplasia, high grade dysplasia, intramucosal carcinoma, and eventually invasive EAC. Unfortunately, most EAC is diagnosed at a very late stage, and this accounts for the overall dismal five year survival of less than 20%. This underscores the importance of performing a high quality Barrett's exam, looking for early lesions when they are more manageable or even curable. To assist you with this, the following mnemonic CLEAN has been described previously. This stands for clear, landmarks, extent, attention, and novel imaging, and we'll review each of these in more detail. Assuming the patient's had adequate sedation, proceed by clearing the esophageal mucosa using CO2 insufflation and water, and if necessary, somethicone or N-acetylcysteine to clear bubbles and mucus. Use suction gently without causing trauma to the mucosa. Landmarks. On withdrawal, inspect for the following landmarks, the diaphragmatic hiatus or pinch, the gastroesophageal junction marked by the top of the gastric folds, and squamous columnar junction, also known as the Z line. Most patients with Barrett's have a hiatal hernia, so be vigilant in looking for one, and avoid over-insufflation, which can artificially create the appearance of Barrett's esophagus as shown here. Define the extent of Barrett's using the PREQ criteria as shown here. It's composed as a circumferential measurement, which is the distance from the GE junction to the circumferential extent, and a maximal measurement, which is the distance from the GE junction to the most proximal part of the longest tongue. Short segment Barrett's measure one centimeter to less than three centimeters, and long segment Barrett's measure three centimeters or greater. In this example on the right, the PREQ criteria is C2, M3, and this is consistent with the long segment Barrett's. Pay attention to potential lesions. Deflate the stomach and slowly withdraw the endoscope, inspecting the Barrett's epithelium at a rate of one minute or greater per centimeter, which has been associated with the quadrupling in the detection of high-grade dysplasia or cancer. Inspect with partial insufflation, so you don't flatten any subtle nodules or lesions, and look in between waves of peristalsis. Identify lesions, specifically using the Paris classification as shown on the right, and clearly photodocument your findings. Early cancers are more common on the right wall within the proximal segment, and a clear cap can be helpful in looking for these. Use novel imaging like virtual chromoendoscopy and near-focus to better detect and characterize lesions. In this example on the left of a patient with nondysplastic Barrett's, the mucosa can be seen demonstrating regular appearing gyri and elongated pit patterns in a vasculature that's ordered. However, on the right in a patient with early neoplasia, the mucosa is more disordered and the pit patterns more crowded, and the vasculature is more dilated, aberrant, and densely packed. In this video example, we use a cap to carefully examine the mucosa, and you can appreciate some subtle nodularity using white light. And then upon further inspection with chromoendoscopy, the vasculature appears more dilated and aberrant. This patient ended up having low-grade dysplasia in the mucosal resection specimen. Perform targeted biopsies of lesions first, followed by random four-quadrant biopsies every two centimeters per Seattle protocol. In patients with known dysplasia, do this every one centimeter. Emerging quality tools to help you in your examination include calculation of your neoplasia detection rate, which is defined as the rate of high-grade dysplasia or cancer found at the time of the index screening exam for Barrett's. Four percent may be used as a quality metric. Educational interventions can help improve your quality. And artificial intelligence is anticipated to offer an adjunctive tool in detecting Barrett's lesions, characterizing and assessing depth, interpreting endoscopic findings, as well as reporting blind spots and areas. So take-home points. A high-quality Barrett's exam relies on multiple factors, including adequate time and attention to detail. Look for subtle, visible abnormalities associated with Barrett's-related neoplasia, especially in the GE junction area, right wall, and proximal end of the segment. Document consistently to guide yourself and the future, as well as other endoscopists should therapy be necessary. And perform targeted biopsies, followed by surveillance biopsies per Seattle protocol. Thank you.

ASG video tip

Barrett's esophagus

esophageal adenocarcinoma

CLEAN mnemonic

high-quality examination