What is the classification and management of Barrett's esophagus in a patient over 50 with a history of chronic Gastroesophageal Reflux Disease (GERD) symptoms?

Classification of Barrett's Esophagus

Barrett's esophagus is classified using the Prague C&M criteria to document extent, combined with histopathological grading based on the presence of intestinal metaplasia and degree of dysplasia. 1

Endoscopic Classification System

The Prague classification is the standardized system for documenting Barrett's extent during endoscopy 2, 3, 1:

• C (Circumferential extent): Measures the length of circumferential columnar-lined epithelium above the gastroesophageal junction 1
• M (Maximum extent): Measures the maximum extent of any tongues of columnar epithelium 1
• Minimum diagnostic threshold: At least 1 cm of columnar epithelium must be clearly visible above the gastroesophageal junction 2, 1

Length-Based Classification

Barrett's is further categorized by segment length, which has prognostic significance 2:

• Long-segment Barrett's esophagus (LSBO): ≥3 cm of columnar-lined epithelium 1
• Short-segment Barrett's esophagus (SSBO): <3 cm of columnar-lined epithelium 1

Longer segments carry significantly higher cancer risk: each 1 cm increase in Barrett's length increases the odds ratio for high-grade dysplasia/cancer by 1.17 (95% CI 1.07-1.27), and a 5 cm difference in segment length is associated with a 1.7-fold increase in cancer risk 2.

Histopathological Classification

The definitive diagnosis requires both endoscopic visualization AND histological confirmation from four-quadrant biopsies taken every 1-2 cm throughout the Barrett's segment 2, 3, 1.

Types Based on Metaplasia

Barrett's esophagus with intestinal metaplasia (the most clinically significant type) 1:

• Contains specialized columnar epithelium with acid mucin-containing goblet cells 1
• Carries the highest cancer risk with annual incidence of high-grade dysplasia/cancer of 0.38% 1
• This is the prerequisite criterion for Barrett's esophagus diagnosis according to the American Gastroenterological Association 3

Barrett's esophagus with gastric metaplasia only 1:

• Contains gastric fundal-type or junctional-type epithelium without goblet cells 1
• Carries lower cancer risk 1
• Still requires follow-up endoscopy as >20% of these patients will have intestinal metaplasia found on repeat systematic biopsies due to sampling error 2

Dysplasia Grading Classification

The dysplasia classification system stratifies cancer risk 1:

1. Non-dysplastic Barrett's esophagus: No dysplastic changes present 1
2. Indefinite for dysplasia: Equivocal changes, often related to inflammation 1
3. Low-grade dysplasia (LGD): Neoplastic changes confined to lower epithelial layers 1
4. High-grade dysplasia (HGD): Neoplastic changes throughout full thickness of epithelium 1
5. Intramucosal carcinoma: Invasion into lamina propria but not beyond muscularis mucosae 1

Critical Diagnostic Requirements

All dysplasia diagnoses must be confirmed by an expert gastrointestinal pathologist due to significant interobserver variability, particularly when distinguishing indefinite from low-grade dysplasia 2, 3, 1. Community pathologists frequently overcall dysplasia, especially in the presence of esophageal inflammation 4.

Management Algorithm Based on Classification

For your patient over 50 with chronic GERD:

Non-dysplastic Barrett's esophagus 3, 4:

• Surveillance endoscopy every 3-5 years using Seattle biopsy protocol 3
• At least daily proton pump inhibitor therapy 3

Low-grade dysplasia (after expert pathology confirmation) 4:

• Repeat endoscopy in 8-12 weeks under maximal acid suppression (twice-daily PPI) 2, 4
• Refer to expert endoscopist at center capable of endoscopic resection and ablation 2, 4
• Radiofrequency ablation significantly reduces progression (OR 0.17,95% CI 0.04-0.65) 4
• If ablation not chosen: surveillance every 6 months for first year, then annually 4

High-grade dysplasia 2:

• Endoscopic resection of any visible lesions mandatory before ablation 3, 4
• Goal is complete eradication of intestinal metaplasia 3, 4

Common Pitfalls to Avoid

Do not proceed with management based on community pathology alone for any dysplasia diagnosis—always obtain expert GI pathology review 2, 4. Studies show poor reproducibility of presumptive diagnoses, with only 10-20% of cases with either endoscopic or histological suspicion confirmed as established Barrett's at follow-up 5.

Do not perform surveillance biopsies during active erosive esophagitis (Los Angeles grade C or D)—optimize acid suppression first and repeat after inflammation resolves 2, 4. Active inflammation is a major source of false-positive dysplasia diagnoses 6.

Document visible lesions separately with targeted biopsies taken first, as any visible abnormality requires endoscopic resection for accurate dysplasia grading before proceeding with ablation 2, 3, 4.