The prevalence of cardia versus noncardia gastric intestinal metaplasia in patients with Barrett's esophagus was assessed prospectively. Four-quadrant biopsies were obtained from the cardia from 119 consecutive patients with Barrett's esophagus and 64 control patients. Gastric surveillance biopsies were obtained in 108 of the Barrett's patients and 58 control patients. There was a significantly greater prevalence of cardia intestinal metaplasia in short-segment Barrett's (10.2%), but not traditional Barrett's (3.3%), compared to control patients (0%) (P = 0.009). Dysplastic changes were significantly more frequent in the metaplastic epithelium within the esophagus than in the cardia (P < 0.0001). A significantly greater prevalence of noncardia intestinal metaplasia compared to cardia intestinal metaplasia was found in each of the three groups of patients; however, the prevalence of noncardia intestinal metaplasia between short-segment, traditional, and control patients was not significantly different. Cardia intestinal metaplasia was an infrequent finding in patients with Barrett's esophagus and appears to develop independently from that in the remainder of the stomach.