PRO: The Goblet Cell: Is It Needed for a Diagnosis of Barrett Esophagus, and Does It Impact Surveillance and Treatment?

Abstract

Barrett esophagus and esophageal adenocarcinoma are sequential complications of gastroesophageal reflux disease. The diagnosis of Barrett esophagus leads to surveillance, which is aimed at early diagnosis of adenocarcinoma. Surveillance does not prevent adenocarcinoma. The first and universal requirement for diagnosis of Barrett esophagus is the presence of visible columnar lined esophagus at endoscopy. Without endoscopy, Barrett esophagus remains hidden. In the United States, intestinal metaplasia defined by goblet cells, which has a strong association with adenocarcinoma, is a second requirement for the diagnosis of Barrett esophagus. This limits surveillance to patients at highest risk. Patients with only cardiac mucosa have either no or lower risk of carcinoma until they develop goblet cells. Including patients without goblet cells will result in an increase in the surveillance pool with a likely negative cost-benefit. The more fundamental issue is that present guidelines delay pathologic diagnosis of gastroesophageal reflux disease to the point at which Barrett esophagus is detected. 85% of patients who develop adenocarcinoma have never had an endoscopy. To prevent esophageal adenocarcinoma, pathologic diagnosis of reflux disease must occur prior to the development of Barrett esophagus, however it is defined. Recent evidence and consensus indicate that cardiac mucosa distal to the squamocolumnar junction in the endoscopically normal person represents the pre-Barrett esophagus pathology of gastroesophageal reflux disease. Turning our attention to the presence and length of cardiac mucosa may provide a method of reaching the objective of preventing the late stages of gastroesophageal reflux disease manifested by Barrett esophagus and adenocarcinoma.