ORIGINAL CONTRIBUTIONS Progression or Regression of Barrett’s Esophagus— Is It All in the Eye of the Beholder? Roy Dekel, M.D., Donald E. Wakelin, M.D., Chris Wendel, M.S., Colleen Green, M.S., Richard E. Sampliner, M.D., Harinder S. Garewal, M.D., Ph.D., Patricia Martinez, R.N., and Ronnie Fass, M.D. Section of Gastroenterology, Department of Medicine, Southern Arizona Veterans Affairs Health Care System and University of Arizona Health Science Center, Tucson, Arizona OBJECTIVES: Accurate measurements of Barrett’s esopha- gus length are important in clinical follow-up as well as in studies of therapeutic intervention in Barrett’s esophagus. Our aim was to evaluate both the inter- and intraobserver reliability in measuring Barrett’s length during two consec- utive endoscopies by either the same or different experienced endoscopists. The relationship between Barrett’s mucosa length and the absolute change in Barrett’s length measure- ments on a follow-up endoscopy was also evaluated. METHODS: A total of 96 Barrett’s patients underwent two consecutive endoscopies. The diagnosis of Barrett’s esoph- agus was confirmed by the presence of intestinal metaplasia on biopsy. The Barrett’s esophagus length was carefully measured and recorded during the two endoscopies. Proce- dures were performed by only two experienced endosco- pists, who were not aware of previous endoscopic measure- ments. Only patients with long-segment (3 cm) Barrett’s esophagus were included in this study. RESULTS: The 55 patients who had their consecutive endos- copies performed by the same endoscopist had a mean 1.6-cm difference between the two measurements as com- pared to 1.4 cm in the 41 patients who had their endoscopies performed by different endoscopists (p = 0.3). The agree- ment between the two Barrett’s length measurements was high in both groups, although it was slightly higher for endoscopies performed by the same endoscopist (r = 0.79 vs r = 0.67). Linear regression analysis of the absolute change in Barrett’s length between the two endoscopic measurements and Barrett’s mucosa length demonstrated a significant relationship (r = 0.28, p = 0.005). For every 1-cm increase in the mean length of Barrett’s mucosa, a 0.15-cm increase in the absolute difference between two consecutive endoscopic measurements of Barrett’s length was observed. CONCLUSIONS: Consecutive measurements of Barrett’s length performed by different experienced endoscopists or by the same experienced endoscopist demonstrated a high degree of agreement. A range of variability in Barrett’s length measurement was determined (1.4 –1.6 cm). True regression or progression of Barrett’s mucosa should be considered only if the change is greater than the range of variability. In addition, endoscopists should be well aware that the longer the Barrett’s mucosa the greater the absolute difference in Barrett’s length measurement on follow-up endoscopy. (Am J Gastroenterol 2003;98:2612-2615. © 2003 by Am. Coll. of Gastroenterology) INTRODUCTION Barrett’s esophagus is defined by the replacement of normal esophageal squamous epithelium by specialized intestinal epithelium. This metaplastic change has been long consid- ered to be the result of gastroesophageal reflux (1). The immense interest in Barrett’s esophagus stems from its malignant potential. Studies have demonstrated that Bar- rett’s mucosa is a precancerous lesion for esophageal ade- nocarcinoma, which is currently one of the fastest rising cancers in Western countries (2, 3). Diagnosis of Barrett’s mucosa depends on identifying the abnormal columnar epithelium extending into the distal esoph- agus. Multiple biopsies are necessary to confirm the presence of intestinal metaplasia, the hallmark of Barrett’s esophagus. Once Barrett’s esophagus is suspected, it is essential to describe its length. When measuring the length of the Bar- rett’s mucosa, two anatomic landmarks need to be accu- rately identified. The first one is the esophago-gastric junc- tion, which is defined by the proximal margin of the gastric folds. The second one is the squamo-columnar junction (Z line), which represents the transition point from squamous to columnar epithelium. Normally these two anatomic land- marks coincide, but in Barrett’s esophagus patients the squamo-columnar junction is proximally displaced. The length of Barrett’s esophagus consists of the distance be- tween these two important endoscopic landmarks (4). Endoscopic evaluation of Barrett’s esophagus length re- quires skill and is influenced by various intraluminal factors. The squamo-columnar junction may be obscured by peri- stalsis, respiratory movements, tortuous esophagus, or ero- sive esophagitis. Presence of hiatal hernia may interfere in defining the exact location of the esophago-gastric junction. Over- or under-insufflation of air, faulty measurements (such as from the lips instead of from the incisors), and inappropriate biopsy technique all may compromise proper THE AMERICAN JOURNAL OF GASTROENTEROLOGY Vol. 98, No. 12, 2003 © 2003 by Am. Coll. of Gastroenterology ISSN 0002-9270/03/$30.00 Published by Elsevier Inc. doi:10.1016/S0002-9270(03)00665-8