This is long-segment Barrett's esophagus. You can see the Z-line. There is evidence of salmon-colored mucosa consistent with specialized intestinal metaplasia or Barrett's esophagus with interspersed islands of squamous mucosa. A complete examination entails high-definition white light followed by narrow-band imaging. Landmarks to measure are the end of the gastric folds, which coincide with the gastroesophageal junction, the Z-line, and the hiatal narrowing. As you can see, narrow-band imaging further characterizes Barrett's esophagus with stark contrast between the intestinal metaplasia and squamous epithelium. It is important to assess the hiatal hernia sac and not confuse the mucosa of the gastric cardia with Barrett's esophagus. The presence of palisade vessels can also guide where the top of the gastric folds are. When taking biopsies in the esophagus, make sure to keep the forceps close to the scope and use the scope to target the mucosa rather than advancing the forceps. Turn the scope into the targeted area, push the forceps into the mucosa, push the suction button to grab the mucosa and then pull tissue. This will ensure you obtain good and adequate samples. It is always better to stack the biopsies to keep track. Start distally and then take biopsies 1 cm proximal to the previous 4 quadrant biopsies. Do not rely on the cm markings on the scope because there can be significant excursion with breathing and movement, especially if there is a variable sliding hiatal hernia. As you can see, the biopsy is being taken here with the radial jaw forceps. Turn into the mucosa, suction and pull tissue. The gold standard for tissue biopsies for Barrett's esophagus is the Seattle protocol. In the case of non-displastic Barrett's esophagus, biopsies should be taken in 4 quadrants every 2 cm, whereas in cases of dysplasia, biopsies should be taken every 1 cm per the Seattle protocol. The whole segment of Barrett's needs to be biopsied from the GE junction to the Z line or the SCJ. Take targeted biopsies of suspicious areas separately and place in separate bottles. Radial jaw 4 large capacity forceps are adequate and are the same as the jumbo forceps used in Seattle protocol. The current jumbo forceps need not be used. Sometimes it is better to take 1 bite per pass of the forceps to avoid losing tissue and to ensure adequate tissue with each bite. Obviously this can be quite cumbersome in long segment Barrett's. Now you can see a pattern with the biopsies in 4 quadrant, all stacked a cm above each other. With multiple biopsies, field can become quite bloody, so make sure you wash with water sparingly and suction immediately to avoid aspiration. Spending adequate time in examination is key in order to pick up subtle mucosal changes, especially nodularity, which can signify intramucosal adenocarcinoma. It is recommended to spend at least 1 minute inspecting each cm with focus on the right wall. Care must be taken to wash the mucous off the esophageal walls with water. Mucomyst or simethicone may also be used. Also do not over insufflate the esophagus because that may flatten lesions.

Barrett's esophagus

examination

biopsy process

high-definition white light

narrow-band imaging