Intestinal metaplasia in the esophagus (Barrett’s esophagus) is the major recognized risk factor for esophageal adenocarcinoma, the incidence of which has risen dramatically in the United States and Europe during the past two decades. 1,2 Three types of columnar metaplasia are found in the esophagus: specialized columnar epithelium or intestinal meta- plasia, gastric fundic-type epithelium, and junction- al or cardia-type epithelium. 3 Dysplasia and carci- noma are only associated with specialized columnar epithelium (intestinal metaplasia). This association has led to a revised definition of Barrett’s esophagus as the presence of histologic findings of specialized columnar epithelium in biopsy specimens taken from the tubular esophagus. 4-13 Currently, limited data exist on the extent to which practicing pathol- ogists restrict reporting of Barrett’s esophagus to cases with specialized columnar epithelium and on interobserver variability of interpretation of dyspla- sia in columnar lined esophagus. As an initial exploration of the variability of his- tologic interpretation of columnar lined esophagus in clinical practice, we identified five histologic slides representing different types of columnar lined epithelium from the esophagus. We then submitted these slides to 20 general pathologists in communi- ty practice for review. PATIENTS AND METHODS This study was approved by our institutional review board. Two pathologists (O.C., T.U.) with special interest in gastrointestinal pathology selected histologic slides of five cases of columnar lined esophagus from endoscopical- ly obtained tissue samples. Cases were classified accord- ing to published definitions. 3,4 There were three cases Variable pathologic interpretation of columnar lined esophagus by general pathologists in community practice Mahboob Alikhan, MD, Douglas Rex, MD, Abdul Khan, MD, Emad Rahmani, MD, Oscar Cummings, MD, Thomas M. Ulbright, MD Indianapolis, Indiana Background: Pathologic interpretation of biopsy specimens of columnar lined esophagus guides subsequent endoscopic surveillance and/or surgical intervention. The aim of this study was to evaluate pathologic interpretation of columnar lined esophagus by general pathologists in com- munity practice. Methods: Five histologic slides representing different types of columnar lined esophagus were submitted for review by 20 randomly selected general pathologists in community practice. There were three cases with intestinal metaplasia (one with no dysplasia, one with low-grade dysplasia, and one with high-grade dysplasia) and two cases of gastric metaplasia (one fundic-type and one cardia-type). Results: High-grade dysplasia was identified as such by 30% of pathologists and was called invasive adenocarcinoma by 20%, low-grade dysplasia by 30%, and moderate dysplasia by the remaining 20%. Low-grade dysplasia was identified as such by 35% of pathologists and was called high-grade dysplasia by 20%, moderate dysplasia by 20%, and no dysplasia by 25%. Specialized columnar epithelium with no dysplasia was identified as such by 35%, called low-grade dysplasia by 35%, moderate dysplasia by 15%, indeterminate for dysplasia by 10%, and invasive adenocar- cinoma by 5%. Gastric metaplasia without specialized columnar epithelium was identified as Barrett’s esophagus in 38% of cases. Conclusions: Pathologic interpretation of columnar lined esophagus by community pathologists may be subject to marked interobserver variation.The term Barrett’s esophagus is often used to describe columnar lined esophagus without goblet cells. Because this finding is not clearly asso- ciated with an increased risk of cancer, these data support recent suggestions that the term Barrett’s esophagus be abandoned. Interpretations of both high-grade and low-grade dysplasia should be considered for review by experts in esophageal pathology. (Gastrointest Endosc 1999;50;23-6.) Received July 29 1998. For revision October 5, 1998. Accepted November 19, 1998. From the Department of Medicine, Division of Gastroenterology/ Hepatology, and Department of Pathology, Indiana University School of Medicine, Indianapolis, Indiana. Supported by a Research Award from the American College of Gastroenterology. Reprint requests: Douglas K. Rex, MD, Indiana University Hospital, Room 2300, 550 N. University Blvd., Indianapolis, IN 46202. Copyright © 1999 by the American Society for Gastrointestinal Endoscopy 0016-5107/99/$8.00 + 0 37/1/96015 VOLUME 50, NO. 1, 1999 GASTROINTESTINAL ENDOSCOPY 23