The incidence of esophageal adenocarcinoma (EAC) is rising more rapidly in the U.S. than any other malignancy, increasing over 350% in the past decades. Most cases of EAC are preceded by Barrett's esophagus (BE). Current guidelines recommend routine endoscopic surveillance followed by ablation or resection of high grade dysplasia (HGD) lesions. However, the standard white light endoscopic surveillance requires extensive random biopsies resulting in an inaccurate approach with up to 40% of patients with HGD having undetected EAC, despite undergoing this surveillance as indicated. This proposal develops a fluorescence-based endoscopic imaging platform to image a novel imaging agent, pegulicianine, that is activated by molecular alterations associated with cancer. This novel platform is aimed at accurately detect, in real-time and in-situ, dysplasia within a background of BE. This approach may obviate the need for repeated surveillance with random biopsies. Through this method of early detection of esophageal precancers, the incidence of EAC and cancer-related mortality may be reduced. This proposal will (1) develop an endoscope-agnostic solution that is compatible with the working channel of any therapeutic gastroscope and (2) generate the data package required to support regulatory approvals to conduct clinical testing and validation of the system in humans.