Your Esophagus Pathology Report: Barrett’s Esophagus and Dysplasia

Biopsy samples taken from your esophagus (typically during an endoscopy) are studied by a doctor with special training, called a pathologist. After testing the samples, the pathologist creates a report on what was found. Your doctors will use this report to help manage your care.

The information here is meant to help you understand medical terms you might find in your pathology report after an esophageal biopsy.

About the esophagus

The esophagus is a tubular organ that connects the mouth to the stomach.

The esophagus meets the stomach at a place called the gastro-esophageal junction, or GEJ. When you’re eating or drinking, a special ring of muscle near the GEJ, called the lower esophageal sphincter (LES), opens to allow food and liquids in the esophagus to enter the stomach. At other times, the LES normally stays closed to keep the stomach’s acid and digestive juices from going up into the esophagus.

Normally, the inner lining of the esophagus (mucosa) is made up mainly of squamous cells. Squamous cells are flat cells that look like fish scales when seen under a microscope.

Barrett’s esophagus and intestinal metaplasia

The esophagus is lined mainly with squamous cells, but other parts of the digestive tract, such as the intestines, are lined with column-shaped gland cells known as goblet cells. These cells secrete mucus to help protect the inner lining from digestive acids and other substances.

The esophagus isn’t normally exposed to these substances, so goblet cells aren’t usually needed there. But in some people, acid can escape from the stomach and go up into the lower part of the esophagus. The medical term for this is gastroesophageal reflux disease (GERD), or just reflux. Reflux can damage the normal inner lining of the esophagus. Over time (typically many years), the squamous cells can be replaced by goblet cells, which are more resistant to stomach acid.

When goblet cells are found where they are not supposed to be, like the lining of the esophagus, it is called intestinal metaplasia. Intestinal metaplasia can develop any place squamous mucosa is normally found. When intestinal metaplasia replaces the squamous mucosa of the esophagus, it is called Barrett’s esophagus.

Cancer risk: People who have Barrett’s esophagus have a higher risk of cancer of the esophagus. However, most people with Barrett’s esophagus do not get this cancer.

Follow-up care for people with Barrett’s esophagus typically depends on if dysplasia is present (see below).

Dysplasia

The gland cells in Barrett’s esophagus can become more abnormal over time. This is called dysplasia. Dysplasia is a pre-cancer. Although the cells are abnormal, they do not have the ability to spread to other parts of the body. This condition can be treated.

If you have Barrett’s esophagus, your pathology report will most likely mention dysplasia as well.

If the report says “negative for dysplasia”…

This means that the pathologist did not see any pre-cancerous (premalignant) changes in your biopsy samples.

If the report says there are changes “indefinite for dysplasia”…

This means that your biopsy sample showed Barrett’s esophagus that contains some cells that are abnormal but not abnormal enough to consider them dysplasia. But at the same time, dysplasia can’t be ruled out entirely.

Often, people with these changes have a lot of reflux, which irritates the cells in the esophagus so that they look abnormal under the microscope.

Cancer risk: People who have Barrett’s esophagus with changes indefinite for dysplasia have a small increase in their risk of esophagus cancer, but most do not go on to develop this cancer.

Typical follow-up: If you have these findings, your doctor may ask you to return for another endoscopy and more biopsies, typically within 3 to 6 months, after increasing your medication to treat your reflux. Follow-up schedules can vary, though, so you should discuss what is best for you with your doctor.

Dysplasia can be either low-grade or high-grade, based on how abnormal the cells look under the microscope.

If the report says there is “low-grade dysplasia”…

Low-grade dysplasia means that some of the cells look abnormal. These cells may look like cancer cells in some ways, but unlike cancer, they don’t have the ability to spread to other parts of your body. This is a very early pre-cancer of the esophagus.

Cancer risk: People with Barrett’s esophagus with low-grade dysplasia do have an increased risk of esophagus cancer, but most do not go on to develop this cancer.

Typical follow-up: If you have Barrett’s esophagus with low-grade dysplasia, your doctor might want to do another endoscopy to get more biopsy samples of your esophagus to make sure you do not have something more concerning. In addition, your doctor may ask that your samples be sent to an expert for review.

Your doctor will probably recommend treatment to remove the abnormal area (usually to remove both the area of Barrett’s esophagus and the dysplasia). Your doctor will discuss your treatment options with you.

If the report says there is “high-grade dysplasia”….

High-grade dysplasia means that some of the cells in the area of Barrett’s esophagus look very abnormal. This is a more advanced pre-cancer of the esophagus than low-grade dysplasia.

Cancer risk: People with Barrett’s esophagus with high-grade dysplasia have an increased risk of getting esophagus cancer (higher than people with low-grade dysplasia).

Typical follow-up: If you have Barrett’s esophagus with high-grade dysplasia, your doctor might want to repeat the endoscopy to get more biopsy samples to make sure you don’t already have cancer that wasn’t seen the first time. Your doctor may ask that your biopsy slides be sent to another pathologist for a second opinion.

Since high-grade dysplasia is strongly linked to cancer, your doctor will recommend treating it. Different treatment options may be better in certain situations, so discuss your options with your doctor.

Reactive changes or inflammation

Your pathology report might also mention reactive changes or inflammation, which are responses by the cells lining the esophagus to being irritated. A number of things can irritate the esophagus, including infections and acid from the stomach.

If your report mentions reactive changes or inflammation, your doctor will work with you to find the cause of the irritation and treat it. This can help prevent more serious problems.

To learn more, see Your Esophagus Pathology Report: Reactive or Reflux Changes​.