The disease

Barrett's esophagus (BE) is a change in the lining of the distal esophagus from the normal squamous epithelium to a columnar appearing mucosa with intestinal metaplasia demonstrated by biopsy [1]. Endoscopy with biopsy of the abnormal appearing distal esophagus is necessary to meet the current working definition of BE. Intestinal metaplasia (IM) is an epithelium with goblet cells like the small intestine but with a different architecture reflecting the result of an underlying chronic inflammatory condition - GERD. IM is important because it represents the premalignant lesion for esophageal adenocarcinoma (EAC), the most feared complication of BE and the most rapidly rising incidence cancer in the United States and Western Europe since the mid 1970s [2], [3].

At the time of endoscopy the minimal essential evaluation includes measuring the length of and systematically biopsying the BE. The endoscopic landmarks to identify by centimeters from the teeth include the proximally displaced squamocolumnar junction, the esophagogastric junction (EGJ) and the diaphragmatic pinch. The EGJ is equivalent to the "endoscopic lower esophageal sphincter," the location of the change from the tubular esophagus to the saccular stomach and/or the proximal margin of the gastric folds of the commonly present hiatal hernia with minimal air insufflation [4]. Systematic biopsies are necessary to identify IM in what may be a mosaic of metaplastic epithelium in the Barrett's segment. The precise number of biopsies necessary to identify IM is not defined.

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