How to examine Barrett’s Esophagus

By Professor Prateek Sharma, University of Kansas Medical Center, Division of Gastroenterology, Kansas City, USA

The essential parts of the endoscopic examination in your patients with Barrett’s esophagus could be listed as ‘CLEAN’.  Follow these steps prior to obtaining biopsies from the BE segment, this will lead to a high quality endoscopy in your patients undergoing upper endoscopy.

1) Clear: Get your field as clear as possible

It is very important to wash and flush the surface of the BE segment with sufficient amount of water (simethicone can be added) to have a clean field of vision of the surface and spot any subtle abnormalities.

2) Landmarks: Identify your landmarks

Identification and reporting of landmarks is key to the diagnosis of BE. The gastroesophageal junction (GEJ) is identified as the proximal ends of the gastric folds in a semi-insufflated distal esophagus. In BE patients, the Z-line or squamo-columnar junction is displaced above the anatomic GEJ and is the endoscopically visible demarcation separating the silvery pearl colored esophageal squamous epithelium from the red colored columnar epithelium. Majority of BE patients also have a hiatal hernia and it is important to recognize the diaphragmatic pinch which lies distal to the GEJ.

3) Extent: Measure and report the extent of the the columnar lined esophagus

After locating the important landmarks, the endoscopic extent of BE is expressed as the circumferential (C) – distance from the GEJ to circumferential extent of BE and the maximal (M) – distance from GEJ to the most proximal part of the longest tongue. This allows for a standardized, uniform and validated methodology for endoscopic reporting using the Prague C and M criteria.

4) Attention: Pay attention to your BE inspection time

Similar to the colonoscopy withdrawal time, the BE Inspection Time has been shown to correlate with the detection of high-grade lesions in BE patients. Inspecting the BE epithelium carefully and slowly, at an approximate rate of 1 minute per extent of BE length, has been shown to increase the odds of finding an “endoscopically suspicious lesion” by four times.

5) Novel Imaging: Use newer advanced endoscopic imaging techniques if available

Consider the use of dye spray chromoendoscopy (acetic acid) and virtual chromoendoscopy (such as Narrow band imaging, Blue light imaging or I-scan), which can improve dysplasia detection especially in experienced hands. Try to achieve familiarity with one of these techniques based on availability, your interest and expertise.

All mucosal abnormalities must be carefully identified, reported using the Paris classification and target biopsies obtain before obtaining the random 4 quadrant biopsies every 2 cms (Seattle protocol). Such a structured endoscopic examination and reporting system will help to conduct a high quality examination in patients with BE and to increase recognition of subtle neoplasia and improving patient outcomes.

Professor Prateek Sharma is a pioneer in endoscopic research in this area and well known along with his colleagues for creating and validating the Prague C and M criteria which is globally utilized in the endoscopic reporting of Barrett’s esophagus. Professor Sharma is a Professor of Medicine and the fellowship program director in the Division of Gastroenterology and Hepatology at the University of Kansas School of Medicine and the Veterans Affairs Medical Center in Kansas City, USA.