A subtle lesion?
During a Barrett's surveillance OGD, I notice this small red spot at 6 O'clock.
WHAT IS THE LIKELY HISTOLOGY?
■ Reflux ulcer
I don't think that you get this within Barrett's without dysplasia!
Clear crypt pattern, not that different from surrounding mucosa? Good guess!
Quite possible and would have been my guess IF there was some nodularity associated
■ Early cancer
Impossible as lesion has an organised crypt pattern!
Previous surveillance samples, 3 years earlier had not revealed any dysplasia. However, that red spot shouldn't be there! A reflux ulcer is unlikely as the Barrett's is there because it protects the food pipe from acid. Of course it does this by developing crypts with Goblet cells which secretes protective mucus (of course the pathologists call this process 'metaplasia'). Early texts usually stated that ulceration is common within Barrett's. In my experience, ulceration within Barrett's only happens when dysplasia develops. With the arrival of dysplasia, you begin to see a disappearance of the Goblet cells and of course when the Goblet cells start to dwindle, so does the protective mucus.
In the bottom zoom image you can see that there is a distinct surface crypt pattern at the site of the red spot. Therefore the cells can't be too disorganised, making cancer unlikely.
Actually this turned out to be a spot of LGD. I would have guessed HGD/IMca (pathologists struggle to tell the difference) if there was a visible nodule at the site of the red spot.
Isn't it interesting that even at the very earliest stage of dysplasia, the unstable cells signal the need for more oxygen to nearby vessels?