During a ten-year period, endoscopy demonstrated acid-peptic esophagitis in 439 patients. Forty of these patients (9.1%) had Barrett's esophagus. Adenocarcinoma was present in the columnar epithelium in 15 (37.5%) of the patients with Barrett's esophagus. Hiatal hernias, with symptoms of heartburn, dysphagia, stricture, and ulceration, were found in more than 75% of the patients with Barrett's esophagus. We developed a treatment algorithm. Patients with symptomatic reflux esophagitis should undergo endoscopy with biopsy. If Barrett's esophagus is diagnosed, an antireflux procedure should be performed, preferably a proximal gastric vagotomy with Nissen's fundoplication. Follow-up examination by endoscopy with biopsy and cytology should be performed every six months. Indications for early esophagectomy include progression of cellular dysplasia, carcinoma in situ, and a non-healing Barrett's ulcer following an antireflux procedure. Our data support an aggressive surgical treatment of patients with Barrett's esophagus.