Approaches to oesophageal columnar metaplasia (Barrett's oesophagus).

The oesophageal squamous mucosal ulceration caused by peptic oesophagitis is followed by healing, with metaplastic columnar mucosa in around 12% of patients. The major significance of this condition, oesophageal columnar metaplasia (OCM), is the relatively high risk that it has for development of oesophageal adenocarcinoma. Fibreoptic endoscopy with multiple mucosal biopsies is the only effective method for detection and evaluation of OCM. Peptic oesophagitis merits treatment in its own right in patients with OCM. There are, however, no clear indications that once OCM has developed, successful healing of oesophagitis by medical or surgical therapies has any impact on the risk of malignancy. Management, therefore, hinges on effective treatment of severe oesophagitis before OCM develops, and surveillance for adenocarcinoma in OCM patients in whom oesophagectomy is considered a therapeutic option. Currently, the most effective screening method is to examine for dysplasia multiple closely spaced biopsy specimens from the columnar lined segment. Mild to moderate dysplasia probably warrants yearly endoscopy and multiple specimens. Severe dysplasia indicates a very high risk for invasive adenocarcinoma. In such patients, oesophagectomy should be seriously considered. Currently, there is a lively interest in research into more sensitive and cost-effective methods for screening for adenocarcinoma.