Barrett Esophagus : Microscopic

Image 7 of 36

Image Description

Microscopic Features: For the diagnosis of Barrett esophagus (BE), the guidelines provided by the American College of Gastroenterology require endoscopically abnormal areas in the distal esophagus to show unequivocal intestinal-type epithelium with goblet cells (intestinal metaplasia). In some countries, such as the United Kingdom and Japan, the presence of gastric cardiac-type epithelium which consists solely of mucus-secreting cells is considered sufficient for the diagnosis of BE.

The columnar epithelium shows tall/elongated cells with basally oriented nuclei, while the goblet cells are round with pale blue cytoplasm (acid mucin) that pushes the nucleus to the periphery of the cell. Goblet cells may occur singly or in clusters throughout the columnar epithelium.

It is important to distinguish goblet cells from pseudogoblet cells to not misdiagnose BE. In contrast to true goblet cells, pseudogoblet cells contain clear to pale pink cytoplasm (neutral mucin) and they are arranged in linear clusters along the epithelium.

Additional findings in BE may include scattered inflammatory cells (lymphocytes, plasma cells, neutrophils), pancreatic acinar metaplasia, and the presence of oxyntic or mucous glands.

Image courtesy of: Phoenix Bell, MD.

About the Disease

Barrett esophagus (BE) is a metaplastic replacement of the stratified squamous epithelium of the distal esophagus with columnar epithelium containing goblet cells. US definition requires intestinal metaplasia. In Japan and the UK, goblet cells are not required for the diagnosis. BE is a preneoplastic lesion and increases the risk for esophageal adenocarcinoma (EAC). BE is found in about 5-10% of individuals with symptomatic gastroesophageal reflux disease. It is more common white males with a median age at diagnosis of 55 years. Diagnosis requires both endoscopic and histologic findings. At endoscopy, Barrett mucosa appears orange-pink (salmon colored) and velvety in contrast to pale pink glossy squamous mucosa. In short-segment and long-segment BE, metaplastic epithelium lines < 3 cm or ≥ 3 cm of the distal esophagus respectively. Biopsies are classified as neg. for dysplasia, indefinite for dysplasia, and positive for LGD or HGD. Patients with non-neoplastic BE develop LGD at the rate of 4.3% per year, and HGD at the rate of 0.9% per year. The rate of progression to cancer within 5 years is 20% with LGD and 50% with HGD. Abnormalities in CDKN2A and TP53 may indicate higher risk of progression. Treatment of BE without dysplasia consists of proton pump inhibitors. Patients undergo surveillance endoscopy every 3-5 years. BE with dysplasia can be treated with endoscopic ablation or resection techniques. References:Iacobuzio-Donahue, C. A. & Montgomery E. (2012). Gastrointestinal and Liver Pathology - 2nd Edition. Feldman, M., Friedman, L. S., & Brandt, L. J. (2020). Sleisenger & Fordtran's Gastrointestinal & Liver Disease - 11th Edition. Arnold C, Lam-Hamlin D, and Montgomery E. (2019). Atlas of Gastrointestinal Pathology : A Pattern Based Approach to Neoplastic Biopsies - First Edition. Odze & Goldblum Surgical Pathology of the GI Tract, Liver, Biliary Tract and Pancreas (2014). 3rd edition. Goldblum, J. R. et al (2018). Rosai and Ackerman's Surgical Pathology - Eleventh Edition.

Image 7 of 36