How do you approach surveillance and repeat biopsies in a patient with a diagnosis of intestinal metaplasia (aka Barrett's esophagus) on pathology who appears to have a regular Z-line or <1 cm of salmon mucosa?

I agree with the other responses to this question. One other aspect that can be tricky in patients where you did not do the index endoscopy is that many patients present with the expectation that they will need further surveillance, or have already been told that they will need surveillance at some interval (usually 3-5 years). I agree about having an expert GI pathologist review the slides. We also request a high-quality color copy of her outside EGD report with pictures, so that we can get a better understanding of what the outside GI saw. If there is any question about the biopsies after review, or if there is any question about the endoscopic findings from the pictures, then it may not be unreasonable to do a one-time surveillance EGD, ...

If the salmon colored mucosa is < 1 cm in length, it is endoscopically not consistent with Barrett's esophagus. Junctional intestinal metaplasia does not have an increased risk of adenocarcinoma. I would review the biopsies with an expert pathologist to confirm there is no evidence of dysplasia. If it is intestinal metaplasia of the GEJ, I do not recommend surveillance.

My first step would be to review the pathology with an expert pathologist.