Subject Category: Clinical and Systematic Review

Am J Gastroenterol 2015; 110:662–682; doi:10.1038/ajg.2015.55; published online 14 April 2015

BOB CAT: a Large-Scale Review and Delphi Consensus for Management of Barrett’s Esophagus With No Dysplasia, Indefinite for, or Low-Grade Dysplasia

Cathy Bennett PhD1,53, Paul Moayyedi MD, PhD2,53, Douglas A Corley MD3, John DeCaestecker MD4, Yngve Falck-Ytter MD5, Gary Falk MD6, Nimish Vakil MD7, Scott Sanders MD8, Michael Vieth MD9, John Inadomi MD10, David Aldulaimi MD11, Khek-Yu Ho MD12, Robert Odze MD13, Stephen J Meltzer MD14, Eamonn Quigley MD15, Stuart Gittens PhD16, Peter Watson MD17, Giovanni Zaninotto MD18, Prasad G Iyer MD19, Leo Alexandre MBBS, MRCP20, Yeng Ang MD21, James Callaghan MBBS22, Rebecca Harrison MBChB23, Rajvinder Singh FRACP, FRCP24, Pradeep Bhandari MD25, Raf Bisschops MD26, Bita Geramizadeh MD27, Philip Kaye MD28, Sheila Krishnadath MD29, M Brian Fennerty MD30, Hendrik Manner MD31, Katie S Nason MD, MPH32, Oliver Pech MD33, Vani Konda MD34, Krish Ragunath MD35, Imdadur Rahman MD36, Yvonne Romero MD37, Richard Sampliner MD38, Peter D Siersema MD39, Jan Tack MD40, Tony C K Tham MD41, Nigel Trudgill MD42, David S Weinberg MD43, Jean Wang MD44, Kenneth Wang MD45, Jennie Y Y Wong PhD46, Stephen Attwood MD47, Peter Malfertheiner MD48, David MacDonald DDS, FRCDC49, Hugh Barr MD50, Mark K Ferguson MD51 and Janusz Jankowski MD, PhD52

  1. 1Centre for Technology Enabled Health Research, Coventry University, Coventry, UK
  2. 2McMaster University, Hamilton, Ontario, Canada
  3. 3Kaiser Permanente, Oakland, California, USA
  4. 4Leicester General Hospital, Leicester, UK
  5. 5Case Western Reserve University School of Medicine, Case and VA Medical Center Cleveland, Cleveland, Ohio, USA
  6. 6University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
  7. 7University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
  8. 8NHS Foundation Trust, Warwick, UK
  9. 9Klinikum Bayreuth, Bayreuth, Germany
  10. 10University of Washington School of Medicine, Seattle, Washington, USA
  11. 11Worcestershire Acute Hospitals NHS Trust, Redditch, UK
  12. 12National University Health System, Singapore, Singapore
  13. 13Brigham and Women's Hospital, Boston, Massachusetts, USA
  14. 14Johns Hopkins School of Medicine, Baltimore, Maryland, USA
  15. 15Weill Cornell Medical College and Houston Methodist Hospital, Houston, Texas, USA
  16. 16ECD Solutions, Columbus, Ohio, USA
  17. 17Queen’s University, Belfast, UK
  18. 18Imperial College, St Mary’s Hospital, London, UK
  19. 19Mayo Clinic, Rochester, Minnesota, USA
  20. 20Norwich Medical School, University of East Anglia, Norwich, UK
  21. 21University of Manchester, Manchester, UK
  22. 22Department of Gastroenterology, University Hospital Southampton, Southampton, UK
  23. 23Leicester General Hospital, Leicester, UK
  24. 24Lyell McEwin Hospital/University of Adelaide, Adelaide, South Australia, Australia
  25. 25Queen Alexandra Hospital, Portsmouth, UK
  26. 26University Hospitals Leuven, Leuven, Belgium
  27. 27Department of Pathology, Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
  28. 28Nottingham University Hospitals NHS Trust, Nottingham, UK
  29. 29Gastrointestinal Oncology Research Group, AMC, Amsterdam, The Netherlands
  30. 30Oregon Health and Science University, Portland, Oregon, USA
  31. 31Department of Gastroenterology HSK Wiesbaden, Wiesbaden, Germany
  32. 32University of Pittsburgh, Pittsburgh, Pennsylvania, USA
  33. 33Krankenhaus Barmherzige Brueder, Regensburg, Germany
  34. 34University of Chicago, Chicago, Illinois, USA
  35. 35Queens Medical Centre, University of Nottingham, Nottingham, UK
  36. 36University Hospital Southampton, Southampton, UK
  37. 37Mayo Clinic, Rochester, Minnesota, USA
  38. 38University of Arizona Cancer Center, Tucson, Arizona, USA
  39. 39University Medical Center Utrecht, Utrecht, The Netherlands
  40. 40University of Leuven, Leuven, Belgium
  41. 41Ulster Hospital, Belfast, Northern Ireland, UK
  42. 42Sandwell and West Birmingham Hospitals NHS Trust, West Bromwich, UK
  43. 43Fox Chase Cancer Center, Philadelphia, Pennsylvania, USA
  44. 44Washington University School of Medicine, Saint Louis, Missouri, USA
  45. 45Mayo Clinic, Rochester, Minnesota, USA
  46. 46Yong Loo Lin School of Medicine, National University of Singapore, Singapore
  47. 47Durham University, Durham, UK
  48. 48Otto-Von-Guericke-Universität Magdeburg, Magdeburg, Germany
  49. 49University of British Columbia, Vancouver, British Columbia, Canada
  50. 50Gloucestershire Royal Hospital, Gloucester, UK
  51. 51The University of Chicago Medicine, Chicago, Illinois, USA
  52. 52University Hospitals Coventry and Warwickshire and University of Warwick, Coventry, UK

Correspondence: J Jankowski, MD, PhD, Translational and Systems Medicine, Clinical Sciences Research Laboratories, Clinical Sciences Building, University Hospitals of Coventry and Warwickshire, University of Warwick, Coventry CV2 2DX, UK. E-mail:

53Equal rank first.

Received 1 December 2014; Accepted 3 February 2015
Advance online publication 14 April 2015





Barrett’s esophagus (BE) is a common premalignant lesion for which surveillance is recommended. This strategy is limited by considerable variations in clinical practice. We conducted an international, multidisciplinary, systematic search and evidence-based review of BE and provided consensus recommendations for clinical use in patients with nondysplastic, indefinite, and low-grade dysplasia (LGD).



We defined the scope, proposed statements, and searched electronic databases, yielding 20,558 publications that were screened, selected online, and formed the evidence base. We used a Delphi consensus process, with an 80% agreement threshold, using GRADE (Grading of Recommendations Assessment, Development and Evaluation) to categorize the quality of evidence and strength of recommendations.



In total, 80% of respondents agreed with 55 of 127 statements in the final voting rounds. Population endoscopic screening is not recommended and screening should target only very high-risk cases of males aged over 60 years with chronic uncontrolled reflux. A new international definition of BE was agreed upon. For any degree of dysplasia, at least two specialist gastrointestinal (GI) pathologists are required. Risk factors for cancer include male gender, length of BE, and central obesity. Endoscopic resection should be used for visible, nodular areas. Surveillance is not recommended for <5 years of life expectancy. Management strategies for indefinite dysplasia (IND) and LGD were identified, including a de-escalation strategy for lower-risk patients and escalation to intervention with follow-up for higher-risk patients.



In this uniquely large consensus process in gastroenterology, we made key clinical recommendations for the escalation/de-escalation of BE in clinical practice. We made strong recommendations for the prioritization of future research.