Barrett's oesophagus: the continuing conundrum

Surveillance should be confined to the surgically fit

papers p 1252

In 1950 Barrett wrote a treatise to clarify confusion over oesophagitis which “connote[s] one thing to some people and something quite different to others.”1 He described gastric mucosa extending into the tubular oesophagus as the result of a congenitally shortened oesophagus. The presence of columnar lined epithelium in the oesophagus is now referred to as Barrett's oesophagus. It is associated with chronic gastro-oesophageal reflux disease and an increased risk of oesophageal adenocarcinoma.2 Quantifying this risk, and the best methods for early diagnosis, are still the subjects of considerable debate.

Endoscopically the distal end of the pearly white oesophagus is readily distinguished from the salmon red of the proximal stomach: the so called “Z line” or squamocolumnar junction. However, the location of the Z line may be difficult to identify in cases of intense inflammation, hiatal hernia, and stricture patients with oesophagitis. Extension of the Z line proximally—representing columnar replacement of the squamous epithelium of the distal oesophagus (Barrett's oesophagus)—is seen in 5-15% of patients with peptic oesophagitis.2 Historically one point of confusion has been whether a minimal length of columnar metaplasia is needed to qualify for the diagnosis of Barrett's oesophagus: is it >2 cm, >3 cm, or >5 cm? In part, these arbitrary criteria were established to avoid “false positive” biopsies of intestinal metaplasia which often occur in the gastric …