Original ArticlesIntestinal Metaplasia of the “Cardia” Accurate Differentiation of Gastric or Esophageal Origin With an Expanded Biopsy ProtocolYung, Evan MD*; Li, Xiaodong MD†; Chandrasoma, Parakrama MD, MRCP (UK)‡,§Author Information *Department of Pathology §Emeritus of Pathology, Keck School of Medicine, University of Southern California ‡Los Angeles County+University of Southern California Medical Center, Los Angeles †Department of Pathology, University of California, Irvine, CA Conflicts of Interest and Source of Funding: P.C. declares he is the owner of US Patent “Pathologic Assessment of Lower Esophageal Sphincter damage.” Publication number: US2017/0290542 A1. Allowed; pending issue. The remaining authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article. Correspondence: Parakrama Chandrasoma, MD, MRCP (UK), LAC+USC Medical Center, Room ACTA7-123, 1100 North State Street, Los Angeles, CA 90033 (e-mail: [email protected]). The American Journal of Surgical Pathology: July 2021 - Volume 45 - Issue 7 - p 945-950 doi: 10.1097/PAS.0000000000001665 Buy Metrics Abstract Whether intestinal metaplasia (IM) distal to the endoscopic gastroesophageal junction (GEJ), that is, the cardia, is gastric or esophageal or both is controversial. Biopsies from this region are believed to be unreliable in resolving this issue and are not recommended. Our objective was to develop an accurate method of histologic diagnosis for IM of the cardia. An expanded biopsy protocol was employed in 986 patients irrespective of indication for endoscopy. This sampled columnar lined esophagus (CLE) when present, the endoscopic GEJ defined by the proximal limit of rugal folds, the area 1 cm distal to the GEJ, and distal stomach. The prevalence and associations of IM in these 4 locations were evaluated. IM was found in 79/91 patients with CLE above the GEJ. This was significantly associated with IM at the GEJ in 40/79 patients (P<0.001). The biopsy taken distal to the endoscopic GEJ had IM in 21/79 patients. No patient with CLE had IM in the distal stomach. In patients without CLE, IM was present at or distal to the endoscopic GEJ in 221 patients. In 32 patients, this was significantly associated with IM in the distal stomach (P<0.001). The remaining 189/986 (19.2%) patients had IM limited to the GEJ region. These data, in association with recent evidence, indicate that IM limited to the area distal to the GEJ in patients without distal gastric IM represents microscopic Barrett esophagus in a dilated distal esophagus. This is presently mistaken for IM of the proximal stomach because of a flawed endoscopic definition of the GEJ. Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.