The diagnosis of Barrett's esophagus: goblets, goblets, goblets☆
Section snippets
The Diagnosis of Barrett's Esophagus
Our prerequisite for the diagnosis of Barrett's esophagus is the presence of intestinal-type goblet cells in at least one biopsy from the lower esophagus. The length of the metaplasia can be as short as a few millimeters, i.e., any amount of columnar mucosa in the lower esophagus that has histologic evidence of goblet cells. The goblet cell component of the metaplastic epithelium is believed by virtually all in the field to represent the predisposing cell type for adenocarcinoma. The importance
What's in a name?
At the outset Barrett did not appreciate the significance of what he was describing.6 Even after the description of goblet cells in Barrett's,3 pathologists still diagnosed Barrett's in their absence as “junctional type (cardiac gland) Barrett's” and “fundic type Barrett's.” Even today there are those who would divide Barrett's into a goblet and a nongoblet type.7 We believe that there has been sufficient progress in our knowledge to make the definition more focused because of (1) better
The endoscopic evaluation of a patient with gastroesophageal reflux disease
Landmarks. Traditionally, the diagnosis of Barrett's esophagus is suggested whenever pink columnar epithelium intrudes into the esophagus. This may be in the form of tongues of columnar epithelium or as a circumferential zone of pink mucosa with a proximally relocated squamocolumnar junction (Z-line). The extent of columnar change should be given as the distance between the gastroesophageal junction and the most proximal tip of the pink tongue or the level of the Z-line if there is
Nonintestinalized mucosa in pink tongues of mucosa
When an endoscopist sees short (≤2 cm) pink tongues in the lower esophagus and biopsies them with the question of Barrett's esophagus, three different kinds of mucosa might be encountered. Two of them, i.e., oxyntic gland and cardiac (or a blend of both), prompt us to call that an eccentric Z-line and not Barrett's esophagus. In the endoscopic and biopsy evaluation of more than 250 cases of Barrett's esophagus we have seen nonintestinalized tongues of mucosa extending more than 2 cm into the
Two or three centimeter rules
As indicated, we believe that any length of pink mucosa in the lower esophagus that contains intestinalized mucosa on biopsy qualifies for a diagnosis of Barrett's esophagus—even 5 or 6 mm. On the other hand, in research studies of Barrett's esophagus it is often justified to require at least 2 cm of intestinalized mucosa in the lower esophagus. One reason is so others will accept that bona fide Barrett's esophagus was being studied. A second reason, in the case of studies of regression of
The mystery of intestinal metaplasia of the gastric cardia
The finding of intestinal metaplasia at a normally located Z-line in patients with gastroesophageal reflux disease was reported more than 10 years ago13 and should really come as no surprise. However, only recently has it captured the attention of workers in this field because of the likelihood that cardia cancer, which has many similarities to Barrett's-associated cancers,2 arises from short segments of Barrett's esophagus or from intestinal metaplasia at a normally located Z-line. Also it
Summary recommendations for the diagnosis of Barrett's esophagus
- 1.
Provide the patient record and the pathologist with the location of the gastroesophageal junction, the proximally relocated Z-line, and the location of biopsies.
- 2.
Take the first biopsy specimens 1 to 2 cm below where you believe the lower esophageal sphincter is located. This helps guarantee that all the metaplasia is sampled in the event that the estimate of the location of the LES is too proximal.
- 3.
In suspected Barrett's esophagus (e.g., short tongues), ask the pathologist to do the combined
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Cited by (211)
Etiology and Natural History of Gastroesophageal Reflux Disease and Predictors of Progressive Disease
2019, Shackelford's Surgery of the Alimentary Tract: 2 Volume SetThe Barrett's Gland in Phenotype Space
2015, Cellular and Molecular Gastroenterology and HepatologyCitation Excerpt :Until recently, the unique functional properties of this gland phenotype may not have been properly appreciated. Specialized epithelium displays a rich admixture of goblet cells11,12 against a background of columnar cells that resemble gastric foveolar cells, which contain acid sialomucin and neutral mucin of normal gastric foveolar cells.17–19 This combination of differentiated lineages thus resembles type II intestinal metaplasia in the gastric mucosa, sometimes called the incomplete type, which includes types II and III depending on whether the columnar and goblet cells secrete sialomucins (type II) or sulfomucins (type III).20,21
Carcinoma of the Esophagus
2014, Textbook of Gastrointestinal Radiology: Volumes 1-2, Fourth EditionGastroesophageal Reflux Disease
2014, Textbook of Gastrointestinal Radiology: Volumes 1-2, Fourth EditionHistory and Definition of Barrett Esophagus
2012, Shackelford's Surgery of the Alimentary Tract: Volume 1-2, Seventh Edition
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