Can Barrett's esophagus be diagnosed without intestinal metaplasia?

From the Guidelines

Barrett's esophagus can be diagnosed without intestinal metaplasia, as the British Society of Gastroenterology recognizes the possibility of a diagnosis with gastric metaplasia only, although the presence of intestinal metaplasia is associated with a higher cancer risk. The diagnosis of Barrett's esophagus requires endoscopic evidence of columnar mucosa extending into the esophagus, and histological confirmation of metaplastic epithelium, which can be either intestinal or gastric type 1. The presence of intestinal metaplasia is not always necessary for the diagnosis, as the condition can be a mixture of different phenotypes, where the intestinal type cells can be more or less predominant. However, it is essential to note that the presence of intestinal metaplasia is associated with a higher risk of developing esophageal adenocarcinoma, and surveillance recommendations and cancer risk assessments are based on the presence of intestinal metaplasia 1.

Some key points to consider in the diagnosis and management of Barrett's esophagus include:

• The use of a standardized grading system to define the extent of Barrett's esophagus, such as the Prague classification 1
• The importance of expert gastrointestinal pathologist review to confirm the diagnosis of Barrett's esophagus with low-grade dysplasia 1
• The need for repeat upper endoscopy and surveillance biopsies in patients with confirmed low-grade dysplasia, and the consideration of endoscopic eradication therapy in these patients 1
• The importance of ongoing surveillance and monitoring for patients with Barrett's esophagus, regardless of the presence of intestinal metaplasia, to detect recurrent intestinal metaplasia and dysplasia 1

In terms of the evidence, the most recent and highest quality study is the 2024 NICE guideline on monitoring and management of Barrett's oesophagus and stage I oesophageal adenocarcinoma, which recognizes the possibility of a diagnosis of Barrett's oesophagus without intestinal metaplasia, but also highlights the importance of intestinal metaplasia in assessing cancer risk 1. The 2016 American Gastroenterological Association clinical practice update on the diagnosis and management of low-grade dysplasia in Barrett's esophagus also provides guidance on the diagnosis and management of Barrett's esophagus, including the importance of expert pathologist review and ongoing surveillance 1.

From the Research

Diagnosis of Barrett's Esophagus without Intestinal Metaplasia

• The diagnosis of Barrett's esophagus typically requires endoscopic and histological confirmation of specialized intestinal metaplasia 2.
• However, studies have shown that there can be a discrepancy between macroscopic and histological diagnosis, with some patients having suspected Barrett's esophagus at endoscopy but no specialized intestinal metaplasia on biopsy 3, 2.
• A study found that approximately 71% of patients with suspected columnar-lined esophagus (CLE) remained negative for intestinal metaplasia in the 2 years following the index endoscopy, suggesting that withholding BE diagnosis for individuals with suspected CLE may be appropriate 3.
• Advanced endoscopic imaging techniques, such as narrow-band imaging and acetic acid chromoendoscopy, have been proposed to improve the visualization of dysplastic regions within Barrett's epithelium, but their impact on daily clinical practice is still being evaluated 4, 5.
• A retrospective analysis found that the use of these advanced imaging techniques did not result in an increased detection rate of dysplasia in routine clinical practice, and that quadratic biopsy sampling remains a recommended approach for surveillance programs 5.

Challenges in Diagnosing Barrett's Esophagus

• The focal distribution of intestinal metaplasia can make it difficult to detect, emphasizing the importance of an adequate biopsy protocol 2.
• Patient demographics, body mass index, gastro-esophageal reflux disease symptoms, hiatal hernia, and endoscopists' identity were not significantly associated with the outcome on repeat endoscopy, suggesting that other factors may influence the diagnosis of Barrett's esophagus 3.
• The length of CLE on index esophagogastroduodenoscopies was slightly longer among patients with definite BE on repeat endoscopy, but this difference was not statistically significant 3.

Current Guidelines and Recommendations

• The current recommended surveillance method for Barrett's esophagus is targeted biopsies of any abnormalities followed by random four-quadrant biopsies every 2 cm using standard white light endoscopy 4.
• Guidelines advocate for the continued use of quadratic biopsy sampling within general surveillance programs, rather than relying solely on advanced imaging techniques 5.
• The identification of goblet cells in Barrett's esophagus is an important aspect of diagnosis, and various techniques have been developed to aid in this process 6.