Primary Motility  Disorders of the  Esophagus
 The Esophageal
 Esophagogastric  Junction

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Volume: Barrett's Esophagus
Chapter: Diagnosis

What is the histological correlation with clinical and endoscopic evidence of Barrett's esophagus?

J.E. Richter (Cleveland)

Many gastroenterologists believe that the diagnosis of Barrett's esophagus is made by endoscopy and confirmed by histology. That is to say, the presence of pink gastric appearing mucosa above the proximal folds of a hiatal hernia defines the presence of Barrett's esophagus. In fact, the likelihood of finding specialized intestinal metaplasia (IM), the histologic marker of this disease, in the endoscopically defined Barrett's esophagus appears to be directly related to the extent of the columnar lining.

Spechler et al. [1] first noted that the frequency of finding specialized intestinal metaplasia in biopsy specimens obtained at the squamocolumnar junction increased from 15% for patients with no columnar lining visible in the esophagus to 93% for patients with greater than 3 cm of esophageal columnar epithelium (Figure 1). In a study of 146 patients with suspected Barrett's esophagus at endoscopy, Eloubeidi et al. [2] confirmed specialized IM in 25% of patients with less than 3 cm of suspected Barrett's esophagus, 50% in patients with 3 to 5 cm and greater than 65% in patients with greater than 5 cm. Multivariant logistic

Figure 1. Results of study showing how the frequency of finding specialized intestinal metaplasia varies with the extent of esophageal columnar lining. (Data from [1])

regression identified only the length of the columnar appearing segment (OR = 3.33, 95% Cl, 1.54-7.17) and race (OR = 2.31, 95% Cl, 0.88-6.03) to be associated with the presence of IM on biopsy. Finally, my group at the Cleveland Clinic has recently looked at our consecutive experience with 65 patients with endoscopically suspected Barrett's esophagus. Our endoscopic diagnosis was confirmed by histology in 14/15 (93%) of patients with long segment Barrett's esophagus (LSBE). However, only 19/50 (38%) of patients with suspected short segment Barrett's esophagus (SSBE) had the diagnosis confirmed by histology.

These studies confirm that the endoscopic diagnosis of LSBE is usually confirmed in over 75% of cases, while we are correct with our diagnosis of SSBE by endoscopy in less than one-third of cases. Therefore, histology rather than endoscopy is the gold standard for making the diagnosis of Barrett's esophagus.


1. Spechler SJ, Zeroogian JM, Wang HH, et al. The frequency of specialized intestinal metaplasia at the squamocolumnar junction varies with the extent of columnar epithelium lining the esophagus. Gastroenterology 1995;108:A224.

2. Eloubeidi MA, Provenzale D. Does this patient have Barrett's esophagus? The utility of predicting Barrett's esophagus at the index endoscopy. Am J Gastroenterol 1999;94:937-943.

Publication date: August 2003 OESO©2015