1.1 Overdiagnosis of Barrett’s esophagus

Incorrectly labeling an irregular Z-line (<1 cm) as BE leads to unnecessary surveillance and patient anxiety. True BE requires clear identification of columnar mucosa extending ≥1 cm above the gastroesophageal junction.

1.2 Inadequate endoscopic inspection

Failure to spend sufficient time inspecting the Barrett segment results in missed neoplasia. Detection improves with longer inspection time (≥1 min/cm) and optimized mucosal visualization.

1.3 Poor mucosal preparation and imaging technique

Skipping cleaning and rushing to random biopsies reduces the ability to detect subtle lesions. Careful cleaning with acetylcysteine and systematic inspection with acetic acid chromoendoscopy (AAC) are essential for lesion recognition.

1.4 Failure to recognize subtle neoplastic lesions

Early neoplasia is often flat and easily overlooked, particularly by non-expert endoscopists. Detection rates are significantly higher in expert centers, highlighting the role of training and experience.

1.5 Overreliance on histology without endoscopic correlation

A benign biopsy from a visible suspicious lesion may be misleading due to sampling error or mistargeting. Visible abnormalities should not be dismissed based solely on histology.

1.6 Interobserver variability in pathology

Low-grade dysplasia is frequently overdiagnosed; up to 73–85% of cases are downgraded after expert review. This variability directly impacts management decisions.

1.7 Incorrect application of the Prague classification

Failure to systematically apply the Prague C & M classification leads to inconsistent diagnosis, poor risk stratification, and inability to compare findings across endoscopies. The extent of Barrett’s esophagus should always be described using the circumferential (C) and maximal (M) lengths. Frequent errors include not identifying the true gastroesophageal junction (GEJ), measuring BE length without adequate insufflation, leading to underestimation, ignoring short tongues or islands, resulting in incomplete M classification. These errors impair risk stratification, as BE length is a key determinant of neoplastic progression risk and surveillance intervals.

1.8 Failure to use the Paris classification for visible lesions

Visible lesions within BE must be described using the Paris classification to guide management. Common mistakes include not recognizing subtle lesions as “visible” (especially flat 0-IIa or 0-IIb lesions), misclassifying lesion morphology, particularly failing to distinguish superficial from depressed (0-IIc) lesions, which carry higher risk of submucosal invasion, proceeding directly to biopsy or ablation without formal lesion characterization.

2.1 Poor adherence to biopsy protocols (Seattle protocol)

Four-quadrant biopsies every 2cm are recommended but poorly followed in practice, with adherence rates as low as 30–50%. This leads to missed dysplasia.

2.2 Sampling error inherent to random biopsies

Even with correct technique, biopsies sample only 4-6% of the Barrett mucosa, making missed dysplasia inevitable.

2.3 Inadequate use of advanced imaging

Failure to use high-definition endoscopy, chromoendoscopy, or virtual chromoendoscopy reduces detection of early neoplasia.

2.4 Incorrect surveillance intervals

Applying uniform surveillance intervals without risk stratification leads to both over-surveillance of low-risk patients and under-surveillance of high-risk groups.

2.5 Surveillance of inappropriate patients

Continuing surveillance in patients with limited life expectancy or minimal disease (<1cm) adds burden without benefit.

2.6 Failure to recognize limitations of surveillance

16.4-38% of esophageal adenocarcinomas are diagnosed within a year of surveillance endoscopy for Barrett’s esophagus, reflecting missed lesions rather than rapid progression.

2.7 Lack of expert involvement

Outcomes are inferior when surveillance is performed outside specialized centers. Expertise improves lesion detection and protocol adherence.

3.1 Ablating instead of resecting visible lesions

Visible lesions must be resected (endoscopic mucosal resection/ endoscopic submucosal dissection) before ablation. Ablation of visible neoplasia delays diagnosis and worsens outcomes.

3.2 Initiating therapy without confirmed dysplasia

Given high interobserver variability, dysplasia – especially low-grade dysplasia – requires confirmation by expert pathologists before treatment.

3.3 Treating inflamed mucosa

Biopsies or ablation of inflamed BE increase misdiagnosis and reduce treatment efficacy. Acid suppression and reassessment are required.

3.4 Inadequate lesion assessment before therapy

Failure to properly delineate lesions or stage disease leads to inappropriate therapy selection and incomplete treatment.

3.5 Poor technical execution and planning

Errors such as not marking lesions, inadequate visualization, or poor bleeding control compromise outcomes of endoscopic resection.

3.6 Performing therapy without sufficient expertise

Endoscopic therapy requires training and volume. Centralization in expert centers improves outcomes and reduces complications.

3.7 Inadequate post-treatment follow-up

Early biopsies or failure to confirm eradication of dysplasia can lead to false reassurance or missed recurrence.