Every piece of a Barrett vignette is downstream of the definition, so this episode starts there and holds it precisely: a visible columnar segment above the gastroesophageal junction plus intestinal metaplasia on biopsy. From that anchor the Prague criteria, the goblet-cell debate, and the dysplasia-driven surveillance intervals all follow. The case. Endoscopy shows salmon-colored mucosa extending 2 cm above the top of the gastric folds, and biopsies return columnar mucosa without goblet cells. Is this Barrett esophagus by the American definition, and what do you do next? Topics coveredThe two-part American definition: columnar mucosa >=1 cm above the GEJ plus intestinal metaplasiaLocating the gastroesophageal junction: top of the gastric folds as the anchorThe 1 cm floor: shorter salmon mucosa is intestinal metaplasia of the cardiaAmerican (goblet cells required) versus British (columnar alone) definitionsPrague C and M criteria for describing segment lengthPathogenesis: metaplastic response to chronic acid and bile injuryThe dysplasia ladder: no dysplasia, indefinite, low-grade, high-gradeSurveillance intervals keyed to segment length and dysplasia gradeSeattle protocol biopsies and the role of expert pathology confirmationChemoprevention: PPI and the AspECT trial signal for aspirin Key decisionsNo goblet cells on a <1 cm salmon segment is intestinal metaplasia of the cardia, not Barrett by the American definition: do not enroll in Barrett surveillanceLow-grade and high-grade dysplasia both require confirmation by a second expert GI pathologist before acting, because interobserver variability is highConfirmed low-grade dysplasia favors endoscopic eradication over surveillance in most patients; high-grade dysplasia mandates eradicationSurveillance interval is set by segment length and the highest dysplasia grade, not by symptomsNondysplastic Barrett is surveilled, not ablated by default, and every patient stays on a PPI For the full chapter with MCQs, tables, and primary-guideline references, visit www.boardpearls.com.Questions or feedback: [email protected]. (00:00) - Opening: the definition drives everything (01:30) - Locating the gastroesophageal junction (04:00) - The 1 cm floor and cardia metaplasia (06:00) - American versus British goblet-cell debate (09:00) - Prague criteria and segment description (12:00) - The dysplasia ladder (15:00) - Surveillance intervals and the Seattle protocol (18:00) - PPI and chemoprevention

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“What did the council decide on item 42?” — answered with the speaker and the moment.

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