Decisions have to be based on indecisive data

In Barrett's oesophagus the stratified squamous epithelium that normally lines the distal oesophagus is replaced by an abnormal columnar epithelium that has intestinal features.1 The abnormal epithelium (called specialised intestinal metaplasia) usually shows evidence of DNA damage that predisposes to malignancy,2 and most oesophageal adenocarcinomas seem to arise from this metaplastic tissue.3 Barrett's oesophagus affects mainly white men, among whom the incidence of oesophageal adenocarcinoma has more than quadrupled over the past few decades.4 The quandary is to know what to do to prevent Barrett's oesophagus from turning into oesophageal cancer.

Barrett's oesophagus develops as a consequence of chronic gastro-oesophageal reflux disease (GORD), and is usually discovered during endoscopy performed to evaluate the symptoms of reflux disease. Endoscopists recognise Barrett's oesophagus because the dull red of the metaplastic columnar epithelium contrasts sharply with the pale glossy normal squamous lining (figure).

Barrett's oesophagus is classified as long segment or short segment, depending on whether or not the specialised intestinal metaplasia extends 3 cm or more above the gastro-oesophageal junction.5 Among patients who have endoscopy for symptoms of reflux, long segment Barrett's oesophagus is found in 3-5% and short segment disease in 10-15%.1 Although it is not clear whether long and short …