S0442 Natural History of Barrett’s Esophagus in Cirrhotic Patients Undergoing Liver Transplantation

Abstract

INTRODUCTION: Barrett’s esophagus (BE) is incidentally diagnosed in patients with liver cirrhosis who undergo upper endoscopy for esophageal variceal screening and surveillance. The management of BE in this context is poorly described and higher rates of progression have been reported. A prevailing concern is the use of immunosuppression in cirrhotic patients with BE undergoing transplantation, with reported accelerated progression to esophageal adenocarcinoma (EAC). We aimed to assess the natural history of BE in patients undergoing liver transplantation (LT) to better understand whether immunosuppression affects progression in BE. METHODS: Patients were identified from an academic medical center according to ICD-10 codes. Only patients with confirmed liver cirrhosis and both endoscopic and histologic confirmation of BE were included in the study. Review of the EMR was conducted to abstract clinical variables. Prevalent dysplasia was defined as dysplasia diagnosed at index endoscopy and incident dysplasia as dysplasia diagnosed during endoscopic surveillance. RESULTS: A total of 40 patients met inclusion criteria. Of these, BE was diagnosed pre-LT in 27 (67.5%) and post-LT in 13 (32.5%). Median follow up after LT and BE diagnosis was 8.2 and 7.9 years, respectively. Post-LT BE was diagnosed at a median of 7 years after LT. Clinical characteristics are presented in Table 1. BE-related and demographic characteristics did not significantly differ between those diagnosed with BE before or after LT. Dysplasia was found in 5 patients (12.5%), of which it was prevalent in 3 and incident in 2. Progression to high-grade dysplasia (HGD) or EAC only occurred in 3 patients. A fourth patient experienced progression from non-dysplastic BE to low-grade dysplasia. Both post-LT progressors were found to have intramucosal EAC and underwent endoscopic resection. All other patients with dysplasia were treated endoscopically and achieved complete eradication of dysplasia and intestinal metaplasia. CONCLUSION: BE-related neoplasia occurs in cirrhotic patients with similar frequency to historical data for non-cirrhotics. In this cohort of patients undergoing LT with long-term follow up, the risk of progression to HGD/EAC does not appear to be increased by iatrogenic immunosuppression. No cases of invasive or metastatic EAC were encountered and all patients were safely and effectively managed with endoscopic therapy. These data support the application of current BE management guidelines to cirrhotic patients undergoing LT.Table 1.: Clinical characteristics in the study population