Barret esophagus

intestinal metaplasia of the esophageal mucosa induced by chronic reflux.

• Histopathological examination of the mucosa shows a columnar epithelium instead of the normal squamous epithelium.

• A premalignant change that requires close surveillance.

• Male sex

• European descent

• Age ≥ 50 years

• Obesity

• Symptoms ≥ 5 years

• Reflux esophagitis → stomach acid damages mucosa of distal esophagus → nonkeratinized stratified squamous epithelium is replaced by nonciliated columnar epithelium and goblet cells (intestinal metaplasia, Barrett metaplasia)

• The physiological transformation zone (Z line) between squamous and columnar epithelium is shifted upwards.

• Short-segment (< 3 cm of columnar epithelium between Z line and GEJ)

• Long-segment (> 3 cm of columnar epithelium between Z line and GEJ): higher cancer risk

esophageal adenocarcinoma

• PPI therapy

  • Consider if asymptomatic.

  • Continue maintenance therapy long-term if symptomatic.

• Endoscopy with four-quadrant biopsies at every 2 cm of the suspicious area (salmon-colored mucosa)

  • If no dysplasia: Repeat endoscopy every 3–5 years.

  • If indefinite for dysplasia: Repeat endoscopy with biopsies after 3–6 months of optimized PPI therapy.

  • If low-grade dysplasia:

    • Endoscopic therapy of mucosal irregularities

    • Alternatively: surveillance every 6-12 months with biopsies every 1 cm

  • If high-grade dysplasia: endoscopic treatment of mucosal irregularities, e.g., radiofrequency ablation

• Consider antireflux surgery or resection of the segment based on a specialist's evaluation.