Who Should Be Screened for Barrett’s Esophagus?

Screening is about absolute risk

GERD is common and Barrett's esophagus is much less common. Screening every patient with reflux would expose large numbers of low-risk people to endoscopy for modest yield. The purpose of risk-based screening is to enrich the screened population for clinically meaningful Barrett's esophagus and dysplasia.

Who is most likely to benefit?

The classic higher-risk profile is a man older than 50 with chronic or frequent GERD plus obesity, smoking history, White race or a first-degree family history. Family history is especially important because it can substantially change the pretest probability. The updated ACG guideline broadened thinking beyond an inflexible age/sex rule and encourages consideration of multiple risk factors.

What should the screening examination accomplish?

A screening EGD should be a high-quality examination of the gastroesophageal junction with careful identification of landmarks. Suspected Barrett's mucosa should be described using a standardized extent classification and biopsied appropriately. If erosive esophagitis obscures the junction, repeat endoscopy after healing may be needed to evaluate for underlying Barrett's esophagus.

A negative high-quality exam usually ends screening

Repeated screening after a negative examination is generally low yield unless the initial examination was compromised—for example by significant esophagitis. A screening program should therefore emphasize quality on the first examination rather than serial low-value procedures.

A practical clinical approach

1. Confirm chronic GERD or another reason to suspect Barrett's esophagus.
2. Count additional risk factors: age, sex, central obesity, smoking, race/ethnicity and family history.
3. Offer screening when cumulative risk is meaningfully elevated and the patient would be a candidate for surveillance or treatment if Barrett's is found.
4. Perform a high-quality EGD with standardized landmark documentation and appropriate biopsies.
5. If the exam is negative and adequate, avoid routine repeat screening.

Common errors to avoid

• Screening all adults with occasional reflux.
• Ignoring family history.
• Failing to document the gastroesophageal junction and Barrett's extent precisely.
• Repeating a normal high-quality screening examination without a new clinical reason.

What should trainees remember?

Barrett's screening is selective. The question is not 'Does this patient have GERD?' but 'Is this patient's combined risk high enough that finding Barrett's would change management?'

Free further reading from Dr. Alan B. R. Thomson

See Dr. Thomson's Best Practice Guidelines in Gastroenterology Disorders and Endoscopy and Diagnostic Imaging for complementary esophageal and endoscopic review.

Frequently asked questions

Should every patient with GERD have screening endoscopy?

No. Screening is targeted to patients with multiple Barrett's/esophageal adenocarcinoma risk factors.

Does a woman with GERD ever need Barrett's screening?

Yes, selectively, when several strong risk factors materially raise risk.

Should screening be repeated after a normal exam?

Usually not after an adequate negative examination, unless severe esophagitis or another factor limited the initial assessment.

References

1. Thomson ABR. Best Practice Guidelines in Gastroenterology Disorders. CAPstone Academic Publishers; 2024. ISBN 979-8398710120.

2. Thomson ABR. Endoscopy and Diagnostic Imaging, Parts I-II. CAPstone Academic Publishers; 2012. ISBN 978-1477400579 and 978-1477400654.

3. Shaheen NJ, Falk GW, Iyer PG, Souza RF, Yadlapati RH, Sauer BG, Wani S. Diagnosis and Management of Barrett's Esophagus: An Updated ACG Guideline. Am J Gastroenterol. 2022;117:559-587.

4. Zhou MJ, et al. Surveillance Endoscopy in Barrett's Esophagus: Does It Work? American College of Gastroenterology Evidence-Based GI. 2025.