S4188 Progression to High-Grade Dysplasia in Barrett’s Esophagus With Sub Centimeter Z-Line

Introduction: We present a case illustrating the diagnostic challenges of short segment Barrett’s esophagus (BE) that progressed to high-grade dysplasia (HGD), despite Z-line irregularities consistently measuring 1 cm or less. Current guidelines do not recommend routine biopsies of Z-lines under 1 cm in the absence of visible mucosal abnormalities. Case Description/Methods: A 71-year-old woman with cirrhosis (alcohol and hepatitis C-related) and prior Whipple procedure for a duodenal carcinoid tumor first presents at age 63 with recurrent upper and lower gastrointestinal bleeding. Her initial episode involved rectal bleeding and symptomatic anemia. Esophagogastroduodenoscopy (EGD) revealed severe distal ulcerative esophagitis. She started on pantoprazole 40 mg twice daily. In 2019, EGD showed a 1 cm irregular Z-line with biopsies revealing Barrett’s esophagus indefinite for dysplasia (IND). A 2021 EGD noted a 6-millimeter irregular Z-line, with biopsies showing intestinal metaplasia. In January 2025, she presented again with hematochezia and a hemoglobin drop from 14.6 to 10.5 grams per deciliter. Repeat EGD revealed a Z-line measuring less than 1 cm, without mucosal abnormalities. Biopsies revealed progression to Barrett’s esophagus with low-grade and focal high-grade dysplasia. She remains minimally symptomatic on proton pump inhibitor therapy. Current management includes acid suppression, lifestyle modification, and surveillance. She is undergoing evaluation for radiofrequency ablation and endoscopic mucosal resection, with multidisciplinary input due to her comorbidities. Discussion: Short segment BE, even with a Z-line under 1 cm, can progress to HGD. This case supports revisiting biopsy protocols in selected high-risk patients and reinforces vigilance in those with prior BE-IND. Notably, this case highlights that Z-lines less than 1 cm can harbor dysplasia. All 3 EGDs -2019, 2021 and 2025-showed Z-lines measuring 1 cm or less, yet histologic progression occurred from IND to intestinal metaplasia to HGD. Though guidelines do not recommend biopsying Z-lines less than 1 cm; doing so in this case enabled early detection. The progression risk of BE-IND remains unclear; while often considered low, studies show that IND can progress to HGD or esophageal adenocarcinoma, particularly in high-risk patients. This case underscores the need for individualized surveillance and reconsideration of current biopsy guidelines.