The quest for intestinal metaplasia--is it worth the effort?

The columnar-lined esophagus (CLE) has remained an enigma for several decades. Starting with the basics, the definition and diagnosis of Barrett's esophagus (BE) continues to be a point of major debate globally leading to definitions that have been restrictive (requiring histologically confirmed intestinal metaplasia) or all-encompassing (simply the presence of CLE at endoscopy). The interest in intestinal metaplasia stems from studies that have consistently demonstrated intestinal metaplasia and dysplasia both adjacent to and remote from esophageal adenocarcinoma. The proponents of not requiring histology suggest that if a sufficient number of biopsies is obtained over an adequate period of time, intestinal metaplasia can usually be demonstrated in such cases and that the true neoplastic potential of the cardiac and fundic-type mucosa detected in the CLE has not been delineated. The optimal number of biopsies required to detect intestinal metaplasia is largely unknown, and in this issue of The American Journal of Gastroenterology, Harrison et al. add to the limited data on this subject. There is ample evidence that once a diagnosis of BE is made, it has significant implications on the financial, psychosocial, and insurance status of the patients. We feel that an optimal, practical definition of BE requires clear, accepted, reproducible, and clinically relevant criteria with evidence of an increased risk of cancer--the most crucial consequence of the lesion--and discuss the pros and cons of the need for documenting intestinal metaplasia in the CLE.