When the distal esophagus is lined by a segment of columnar epithelium that is abnormal either because it is extensive or because it has intestinal features, the condition is called Barrett's esophagus. Traditionally, Barrett's esophagus has been associated with severe gastroesophageal reflux disease (GERD) and with a high risk for adenocarcinoma. Recently, investigators have shown that short segments of intestinal metaplasia can be found frequently in the distal esophagus of patients who have few signs and symptoms of GERD. For these patients, the risk for carcinogenesis is not clear. This article summarizes the diagnostic and clinical features of Barrett's esophagus and presents an approach to the management of patients with this fascinating disorder.