What the gastroenterologist needs to know about the histology of Barrett's esophagus.

PURPOSE OF REVIEW

The purpose of this review is to provide clinicians with an up-to-date summary of the terminology, classification, biological characteristics, and limitations of pathology regarding Barrett's esophagus and associated neoplastic precursor lesions in order to optimize decision making when evaluating patients with this disorder.

RECENT FINDINGS

This review summarizes some of the advancements and controversies regarding the definition and diagnostic criteria for Barrett's esophagus, difficulties that arise when trying to differentiate esophageal versus gastric epithelium in gastroesophageal junction (GEJ) biopsies, the histology and biology of nondysplastic Barrett's esophagus including columnar metaplasia without goblet cells, and the limitations and diagnostic variability in interpretation of conventional and nonconventional types of dysplasia in Barrett's esophagus.

SUMMARY

The definition of Barrett's esophagus is controversial, particularly with regard to the need to identify goblet cells in esophageal biopsies. In most cases, morphologic evaluation of GEJ biopsies cannot help distinguish whether the columnar epithelium comes from the distal esophagus versus the proximal stomach. Metaplastic esophageal columnar epithelium that does not contain goblet cells nevertheless is biologically intestinalized, shows molecular abnormalities, and has been shown to be at risk for progression to cancer, but the magnitude of that risk is unknown. Interobserver agreement on the presence, grade, and type of dysplasia remains moderate at best, particularly in light of the recent recognition of nonconventional types of dysplasia, such as foveolar, serrated, and early crypt dysplasia, which make interpretation difficult. Close cooperation between clinicians and pathologists is essential in order to ensure proper interpretation of biopsy results and to provide optimal surveillance and treatment decisions.