Endoscopic Diagnosis of Barrett's Esophagus
Key Endoscopic Features
- The American Gastroenterological Association recommends that columnar epithelium must be clearly visible endoscopically (≥1 cm) above the gastroesophageal junction (GOJ), measured using the Prague C&M classification system 1, 2
- The proximal limit of the longitudinal gastric folds with minimal air insufflation is the easiest and most reliable landmark for identifying the GOJ, with a reliability coefficient of 0.88 3, 4
- Gastric folds have a reliability coefficient of 0.88 for identifying the GOJ 4
- The distal end of palisade vessels can also mark the GOJ, but this has poor reproducibility (κ = 0.14) 3, 4
Documentation and Classification
- All Barrett's esophagus findings must be documented using the Prague classification, which includes C (Circumferential extent) and M (Maximum extent) measurements 1, 5
- The Prague classification has a reliability coefficient of 0.72 for Barrett's ≥1 cm 4, 5
- The C measurement represents the length in centimeters of circumferential columnar lining above the GOJ, while the M measurement represents the maximum length in centimeters of any tongues of columnar epithelium extending above the GOJ 4, 5
Diagnostic Criteria
- Barrett's esophagus should NOT be diagnosed if only an irregular Z-line is present, which is defined as tongues of columnar epithelium <1 cm with no confluent segment 3, 4
- The 1 cm minimum threshold is critical—anything less should not receive a Barrett's diagnosis 3, 4
Histologic Confirmation
- The British Society of Gastroenterology requires intestinal metaplasia for definitive diagnosis of Barrett's esophagus 9, 10
- The American Gastroenterological Association accepts either intestinal-type or cardia-type epithelium, though only intestinal metaplasia has established cancer risk 9
- The Seattle biopsy protocol (four-quadrant biopsies every 2 cm plus targeted biopsies) should be performed for histologic confirmation 5