From Barrett's esophagus to adenocarcinoma and metastasis

The first description of islets of ectopic gastric mucosa in the esophagus was by Schmidt in 1805. One century later, in 1906, Tileston described peptic ulcerations in columnar epithelium lining the distal esophagus. In 1950 Norman Barrett gave a detailed description of the columnar lined esophagus. He regarded the distal columnar lined esophagus a mediastinal extension of the stomach, as a result of a congenitally short esophagus. Barrett based his theory on the nature of the mucosa and mucosal secretions of the columnar lining, whereas absence of the musculature and peritoneal covering of the normal stomach were ignored. In that period Lortat-Jacob described the same condition, which he named endobrachyesophagus, a term still used in French literature. Barrett's observation was that of gastric mucosa, extending as a continuous sheet into the mediastinum. He observed that the columnar mucosa could extend for a varying distance and could reach as far as the aortic arch. Allison and Johnstone in 1953 showed that anatomically and functionally the segment of digestive tract described by Barrett is part of the esophagus. These authors suggested that the so-called Barrett's esophagus might be an acquired rather than a congenital condition. This implies that as a consequence of gastroesophageal reflux, oesophageal squamous epithelium is converted to columnar epithelium through metaplasia. In several studies, authors noted "upward migration" of the squamo-columnar junction during follow-up of patients with gastro-esophageal reflux. Animal experiments proved that columnar epithelium in the esophagus is generated in the presence of gastro-oesophageal reflux. Through these observations it had become apparent that Barrett's esophagus is an acquired rather than a congenital condition. Around 1980 most authors appear to favor the view of the acquired origin of Barrett's esophagus However, congenital islands of ectopic gastric mucosa do occur. They are found in up to 10% of individuals undergoing endoscopy. These so called "inlet patches" occur principally in the cervical esophagus and are mostly surrounded by normal squamous epithelium.

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