Diagnostic criteria for Barrett esophagus

What is essential for the diagnosis of Barrett esophagus?

Paul Moayyedi, MB ChB, PhD: North American guidelines would say that a person needs to have at least 1 cm of Barret esophagus, a columnar-lined esophagus, and you should be able to find intestinal metaplasia on the biopsies. Clinicians seem to focus on the intestinal metaplasia and not the 1 cm.

I would emphasize that endoscopies cannot really detect distances less than 1 cm. They are not very accurate. If you are seeing a slightly irregular Z line and maybe 0.5 cm of Barret esophagus, you can never as a gastroenterologist be sure of that. You cannot diagnose Barret esophagus from very small segments. Even if you find intestinal metaplasia in those segments, that does not mean the patient has Barret esophagus. All that means is that they have intestinal metaplasia at the gastroesophageal junction, which 20% of the population has. Clearly, 20% of the population is not developing esophageal cancer, so this cannot be a major risk factor for anything. Indeed, epidemiology suggests it is not.

Conversely though, if you have a long segment, 3 or 4 cm of a columnal-line esophagus at endoscopy, you biopsy it and do not find intestinal metaplasia, to my mind it does not mean you do not have Barret esophagus. It just means that you have not picked up intestinal metaplasia yet. As long as it is a long segment—not just these very small segments, which I would suggest you could ignore, but the ones over 1 cm—then you just keep trying to find intestinal metaplasia, and usually if you have a long enough segment you will find it eventually. I would always treat those as Barret esophagus. Those with irregular Z lines with intestinal metaplasia on them are not Barret esophagus in my opinion. That is a normal variant and you should not worry patients about that diagnosis in that setting.