Primary Motility  Disorders of the  Esophagus
 The Esophageal
 Esophagogastric  Junction

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Volume: Barrett's Esophagus
Chapter: Diagnosis

What is the level of agreement between the results of histological and cytological detection of benign Barrett's mucosa?

H.H. Wang (Boston)

Barrett's esophagus is defined by the presence of columnar epithelium in the distal esophagus that is abnormal either because of its length or its abnormal (intestinal) features [1]. Since the length of columnar epithelium in the distal esophagus is determined endoscopically, pathologists rely on the endoscopist to correlate the histologic/cytologic findings with the endoscopic observation for the final diagnosis of Barrett's esophagus. Although columnar epithelium in the distal esophagus used to be considered of three type [2], cardiac- and gastric fundic-type mucosa alone are rarely identified above the distal 3 cm of the tubular esophagus and the increased risk of adenocarcinoma has been only associated with the intestinal type [3, 4]. Therefore, pathologists usually equate the presence of intestinal-type epithelium (goblet cells) on microscopy with Barrett's esophagus when the specimen is from the distal esophagus or esophagogastric junction [3]. Most recently, cardiac-type mucosa has been suggested to be an early manifestation of gastroesophageal reflux disease and thus metaplastic in nature [5]. This concept is still unproven and its significance unknown.

Although it has not been studied systematically, the correlation of identifying columnar epithelium on histology and cytology should be good as it can be easily distinguished from squamous epithelium on both histology and cytology. The correlation of histological and cytological identification of intestinal-type epithelium (goblet cells), however, is less than optimal [6] (Table I). The level of agreement is dependent on the extent of metaplastic epithelium as illustrated in Table II. The agreement in patients with endoscopic evidence of columnar epithelium in the distal esophagus is much better than in those without such evidence. When goblet cells are present in a limited number, they are more likely to be missed on either histology or cytology than when they are present in a large number. In addition to sampling error, another source of error on cytology is the presence of nonspecific goblet-appearing mucous cells. These cells are correctly identified on histology due to its pale pink color of the cytoplasm on H&E sections, while the vacuoles of goblet cells are faintly blue or empty. As a result of the processing involved in Papanicolaou stain, the vacuoles in the mucous cells and goblet cells are both empty on Papanicolaou stain. Although the vacuoles in the nonspecific goblet-appearing mucous cells are usually smaller than those in the goblet cells, it is not always possible to make the distinction.

Table I. Histocytological correlation of detection of goblet cells (n = 147) (from [6]).

Table II. Histocytological correlation of detection of goblet cells by endoscopic evidence of columnar epithelium in the distal esophagus (n = 146) (from [6]).

In summary, the degree of agreement of histological and cytological detection of intestinal-type epithelium (goblet cells) depends on the extent of the metaplastic epithelium. The degree of agreement is high when the metaplasia is extensive. It is low when the metaplasia is limited.


1. Spechler SJ. Barrett's esophagus. Semin Gastrointest Dis 1996;7:51-60.

2. Paull A, Trier JS, Dalton MD, Camp RC, Loeb P, Goyal RK. The histologic spectrum of Barrett's esophagus. N Engl J Med 1976;295:476-480.

3. Haggitt RC. Barrett's esophagus, dysplasia, and adenocarcinoma. Hum Pathol 1994;25:982-993.

4. Spechler SJ, Goyal RK. The columnar-lined esophagus, intestinal metaplasia, and Norman Barrett. Gastroenterology 1996;110:614-621.

5. Chandrasoma PT, Lokuhetty DM, DeMeester TR, et al. Definition of histopathologic changes in gastroesophageal reflux disease. Am J Surg Pathol 2000;24:344-351.

6. Wang HH, Sovie S, Zeroogian JM, Spechler SJ, Goyal RK, Antonioli DA. Value of cytology in detecting intestinal metaplasia and associated dysplasia at the gastroesophageal junction. Hum Pathol 1997;28:465-471.

Publication date: August 2003 OESO©2015