Q. Do you always see dysplasia in Barrett esophagus?

A. Good question! No, you don’t always see dysplasia. You worry about it, but most of the time you don’t see it.

What you do always see is metaplasia (a replacement of one cell type with another). In Barrett esophagus, the epithelium of the distal esophagus changes from squamous to columnar epithelium. The weird thing is that the columnar epithelium is not just any old columnar epithelium: it’s intestinal-like¬†columnar epithelium (meaning it has goblet cells in it). Check out the alcian blue-stained section of Barrett esophagus above; the blue-staining cells are goblet cells.

Barrett esophagus occurs in a small number of patients with chronic reflux disease. It’s the body’s attempt to cope with all that acid that’s bathing the lower esophagus (so maybe it does make sense to have some goblet cells in there, secreting some epithelium-protecting mucus). It’s more common in white males between the ages of 40 and 60.

By itself, it’s not a big deal. The concern, though, is that Barrett esophagus increases your chance of getting esophageal adenocarcinoma. A small number of patients with Barrett esophagus (up to 2% of patients each year) develop dysplasia. Low-grade dysplasia may revert back to normal epithelium, but high-grade dysplasia is pretty likely to evolve into invasive adenocarcinoma. The risk of adenocarcinoma in patients with Barrett is said to be somewhere between 30 and 100 times normal. Scary.

Generally, patients with Barrett esophagus are followed with endoscopies every couple years, with biopsies to check for dysplasia. If low-grade dysplasia is found, most clinicians will follow the patient more closely, with more frequent endoscopies, since some of these cases revert to normal. Once high-grade dysplasia develops, most clinicians will recommend treatment, since many of these cases will go on to become invasive adenocarcinoma. Common treatment options include ablation (either with laser or radio waves) or surgery.