Management of Barrett's Esophagus

Introduction to Acid Suppression

Proton pump inhibitors (PPIs) are the preferred treatment for patients with Barrett's esophagus due to their superior acid suppression capabilities and established efficacy for symptom control, as recommended by the British Society of Gastroenterology (Recommendation grade A) 1
PPIs provide more effective and sustained acid suppression compared to H2 receptor antagonists, with a Cochrane review finding PPIs more effective for symptom control in patients with reflux disease 1

Patients with Barrett's esophagus typically have high levels of nocturnal esophageal acid exposure, which PPIs are better equipped to control 2
For patients with long-segment Barrett's esophagus (>3cm), twice-daily PPI therapy may be beneficial 2
Patients with Barrett's esophagus often experience significant nocturnal acid reflux, requiring special attention 2

Current evidence does not definitively support the use of PPIs to prevent progression to dysplasia or cancer, but proper acid suppression helps mitigate this risk (0.1-0.5% per year) 1, 3
Regular dose review is recommended to assess for side effects and prevent potential long-term complications like bone fractures, infections, and electrolyte disturbances 3
The benefits of acid suppression in Barrett's esophagus generally outweigh potential risks of long-term PPI use, with guidelines recommending acid suppression medications for symptom control 1, 3

24-hour pH monitoring is the gold standard test for measuring acid levels in the esophagus over time, and can be performed while on or off PPI therapy 4
Endoscopy with pH testing can directly measure the pH in different areas of the esophagus 4
Wireless pH capsule (Bravo) is a more comfortable alternative to traditional pH monitoring, measuring acid levels for up to 96 hours 4

Proton pump inhibitors (PPIs) like omeprazole effectively reduce acid reflux, contributing to disease progression, regardless of baseline stomach acid levels 1
Optimizing PPI dosing (timing before meals is important) may be beneficial for patients experiencing breakthrough symptoms or concerns 4
The American College of Gastroenterology and the British Society of Gastroenterology recommend continuing PPIs as prescribed, as this is the standard of care for Barrett's esophagus 1