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González Otero L, Seoane Blanco L, García Gómez A, Gómez Rivas M, Armesto Pérez A, López Rosés L. Lymphocytic esophagitis - A little-known cause of dysphagia. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2024. [PMID: 39235204 DOI: 10.17235/reed.2024.10656/2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/06/2024]
Abstract
Lymphocytic esophagitis is a little-known entity whose cause is not fully established, and which basically presents with dysphagia. It is characterized by the presence of an infiltrate mainly formed by lymphocytes and other signs of epithelial damage in the absence of other granulocytes. The lack of knowledge about this pathology as well as standardized diagnostic criteria complicates its diagnosis. We present the case of an 84-year-old male with dysphagia and pathological findings compatible with lymphocytic esophagitis, requiring several lines of treatment and even endoscopic dilation with subsequent clinical improvement.
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Hussein M, Mitchison M, Sweis R. Lymphocytic oesophagitis: diagnosis and management. Clin Med (Lond) 2023; 23:540-544. [PMID: 38065611 PMCID: PMC11298499 DOI: 10.7861/clinmed.2023-0440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Lymphocytic oesophagitis is a rare inflammatory condition that was first described in 2006. Although it is being increasingly diagnosed, it remains poorly described and characterised. There is limited research on the natural history, diagnosis and management of this condition. The most common presenting symptoms are dysphagia, chest pain and heartburn. Endoscopic features can mimic eosinophilic oesophagitis. International consensus is needed to secure a histological definition, to agree on an endoscopic severity scoring system and to determine an appropriate management algorithm. This review summarises the main evidence for the diagnosis and management of lymphocytic oesophagitis, thus setting the scene for the future directions needed to improve the management of this condition.
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Affiliation(s)
| | | | - Rami Sweis
- University College London Hospital, UK and University College London, UK
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Muacevic A, Adler JR. Lymphocytic Esophagitis: Diagnosis and Management in the Emergency Department vs Initial Suspicion of Eosinophilic Esophagitis. Cureus 2022; 14:e30300. [PMID: 36407179 PMCID: PMC9659315 DOI: 10.7759/cureus.30300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/14/2022] [Indexed: 12/03/2022] Open
Abstract
Lymphocytic esophagitis is an increasingly prevalent yet poorly understood condition that is highly disruptive to daily living. The presentation often includes dysphagia, but dysarthria and narrowing of the esophageal lumen may be seen as well. In this case, a 66-year-old female presented to the Emergency Department complaining of dysphagia for several weeks in addition to associated discomfort with the loss of ability to swallow solid foods.
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Caires Silveira E, Santos Corrêa CF, Madureira Silva L, Almeida Santos B, Mattos Pretti S, Freire de Melo F. Recognition of esophagitis in endoscopic images using transfer learning. World J Gastrointest Endosc 2022; 14:311-319. [PMID: 35719896 PMCID: PMC9157692 DOI: 10.4253/wjge.v14.i5.311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 07/15/2021] [Accepted: 04/26/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Esophagitis is an inflammatory and damaging process of the esophageal mucosa, which is confirmed by endoscopic visualization and may, in extreme cases, result in stenosis, fistulization and esophageal perforation. The use of deep learning (a field of artificial intelligence) techniques can be considered to determine the presence of esophageal lesions compatible with esophagitis.
AIM To develop, using transfer learning, a deep neural network model to recognize the presence of esophagitis in endoscopic images.
METHODS Endoscopic images of 1932 patients with a diagnosis of esophagitis and 1663 patients without any pathological diagnosis provenient from the KSAVIR and HyperKSAVIR datasets were splitted in training (80%) and test (20%) and used to develop and evaluate a binary deep learning classifier built using the DenseNet-201 architecture, a densely connected convolutional network, with weights pretrained on the ImageNet image set and fine-tuned during training. The classifier model performance was evaluated in the test set according to accuracy, sensitivity, specificity and area under the receiver operating characteristic curve (AUC).
RESULTS The model was trained using Adam optimizer with a learning rate of 0.0001 and applying binary cross entropy loss function. In the test set (n = 719), the classifier achieved 93.32% accuracy, 93.18% sensitivity, 93.46% specificity and a 0.96 AUC. Heatmaps for spatial predictive relevance in esophagitis endoscopic images from the test set were also plotted. In face of the obtained results, the use of dense convolutional neural networks with pretrained and fine-tuned weights proves to be a good strategy for predictive modeling for esophagitis recognition in endoscopic images. In addition, adopting the classification approach combined with the subsequent plotting of heat maps associated with the classificatory decision gives greater explainability to the model.
CONCLUSION It is opportune to raise new studies involving transfer learning for the analysis of endoscopic images, aiming to improve, validate and disseminate its use for clinical practice.
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Affiliation(s)
- Elena Caires Silveira
- Multidisciplinary Institute of Health, Federal University of Bahia, Vitória da Conquista 45029-094, Bahia, Brazil
| | - Caio Fellipe Santos Corrêa
- Multidisciplinary Institute of Health, Federal University of Bahia, Vitória da Conquista 45029-094, Bahia, Brazil
| | - Leonardo Madureira Silva
- Multidisciplinary Institute of Health, Federal University of Bahia, Vitória da Conquista 45029-094, Bahia, Brazil
| | - Bruna Almeida Santos
- Multidisciplinary Institute of Health, Federal University of Bahia, Vitória da Conquista 45029-094, Bahia, Brazil
| | - Soraya Mattos Pretti
- Multidisciplinary Institute of Health, Federal University of Bahia, Vitória da Conquista 45029-094, Bahia, Brazil
| | - Fabrício Freire de Melo
- Multidisciplinary Institute of Health, Federal University of Bahia, Vitória da Conquista 45029-094, Bahia, Brazil
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Zaver HB, Ghoz H, Malviya BJ, Brahmbhatt B, Palmer WC, Lacy BE, DeVault KR, Krishna M, Bi Y. Lymphocytic Esophagitis: Assessing Risk Factors and Clinical Outcomes. Dig Dis Sci 2021; 66:3976-3984. [PMID: 33216240 DOI: 10.1007/s10620-020-06706-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 11/02/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Lymphocytic esophagitis is a rare esophageal condition. Our knowledge of potential risk factors and treatment outcomes of lymphocytic esophagitis is limited. AIM To investigate potential risk factors associated with the development of lymphocytic esophagitis and compare clinical characteristics and treatment outcomes of patients diagnosed with lymphocytic esophagitis to patients diagnosed with eosinophilic esophagitis. METHODS This is a multicenter retrospective study. Lymphocytic esophagitis patients were identified based on pathology results between 1997 and 2019. Control groups consisted of patients with normal esophageal biopsies and patients diagnosed with eosinophilic esophagitis. Thirteen potential risk factors for lymphocytic esophagitis were analyzed using univariate and multivariate models including IBD, achalasia, hyperlipidemia, hypothyroidism, celiac sprue, CVID, H. pylori, thymoma, aspirin, opioids, ACE-I, metformin, and statin use. Comparative statistics were performed. RESULTS Ninety-four adult patients with lymphocytic esophagitis, 344 with eosinophilic esophagitis, and 5202 control patients with normal esophageal biopsies were analyzed. Age older than 60 [adjusted odd ratio (AOR) 1.03, 95% CI 1.02-1.05, p = 0.001], aspirin use (2.7, 95% CI 1.4-4.9, p = 0.001), statin use (2.2, 95% CI 1.2-4.2, p = 0.01), or a diagnosis of achalasia (2.4, 95% 1.08-5.67, p = 0.03) were associated with lymphocytic esophagitis. Compared to eosinophilic esophagitis, lymphocytic esophagitis patients were more likely to respond to medical treatment (95% CI 2.54-12.8, p = 0.0001). CONCLUSIONS Our data suggests that lymphocytic esophagitis is more likely to be found in older female patients and is significantly associated with achalasia, statin, and aspirin use. Compared to eosinophilic esophagitis, lymphocytic esophagitis is more likely to respond to treatment with medical therapy.
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Affiliation(s)
- Himesh B Zaver
- Department of Internal Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Hassan Ghoz
- Division of Gastroenterology and Hepatology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Balkishan J Malviya
- Division of Gastroenterology and Hepatology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Bhaumik Brahmbhatt
- Division of Gastroenterology and Hepatology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - William C Palmer
- Division of Gastroenterology and Hepatology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Brian E Lacy
- Division of Gastroenterology and Hepatology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Kenneth R DeVault
- Division of Gastroenterology and Hepatology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Murli Krishna
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Jacksonville, FL, USA
| | - Yan Bi
- Division of Gastroenterology and Hepatology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA.
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Neutrophils, eosinophils, and intraepithelial lymphocytes in the squamous esophagus in subjects with and without gastroesophageal reflux symptoms. Hum Pathol 2021; 115:112-122. [PMID: 34181982 DOI: 10.1016/j.humpath.2021.06.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 06/17/2021] [Accepted: 06/18/2021] [Indexed: 02/07/2023]
Abstract
Whilst intraepithelial lymphocytes (IELs) are considered normal within the distal esophageal mucosa, they have an increasingly recognised role in the pathogenesis of reflux esophagitis, and IEL quantification establishes the diagnosis of lymphocytic esophagitis. Knowledge regarding the upper limit of a normal IEL count in health is lacking. We studied 117 non-healthcare seeking adult volunteers from a random community sample (the Kalixanda study) with esophageal biopsies 2 cm above the gastroesophageal junction. Subjects were divided into four groups based on the presence or absence of gastro-esophageal reflux symptoms and/or esophagitis on endoscopy. Asymptomatic subjects with no endoscopic esophagitis were selected as controls, and the cell counts in this group were used to define the upper limit of normal of IELs, eosinophils and neutrophils. The entire sample was used to identify independent predictors of increased cellular counts by logistic regression analysis. None of the healthy controls had an IEL count of more than three per five high power fields (HPF), and therefore this was considered as the upper limit of normal; no controls had eosinophils or neutrophils in esophageal biopsies. Independent predictors of an elevated IEL count were spongiosis on histology (OR 11.17, 95% CI 3.32-37.58, P < 0.01) and current smoking (OR 4.84, 95% CI 1.13-2.71, P = 0.03). A receiver operating characteristics analysis concluded that a threshold of 3 IELs/5HPFs performs best in predicting reflux symptoms when a normal esophageal mucosa is visualized on endoscopy (sensitivity = 100.0%, specificity = 35.2%). The healthy esophageal mucosa does not contain more than three IELs per five HPF in the distal esophagus.
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Wojas O, Żalikowska-Gardocka M, Krzych-Fałta E, Szczepankiewicz B, Samel-Kowalik P, Samoliński B, Przybyłkowski A. A case of lymphocytic esophagitis in a woman with multiple allergies. Allergy Asthma Clin Immunol 2021; 17:56. [PMID: 34099042 PMCID: PMC8186211 DOI: 10.1186/s13223-021-00558-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 05/18/2021] [Indexed: 02/08/2023] Open
Abstract
Background Lymphocytic esophagitis is a newly recognized entity of unknown origin. Dysphagia is defined as difficulty swallowing and represents a common symptom in the general population with a prevalence of approximately 20%. Chronic inflammation of the esophageal wall may manifest itself clinically and endoscopically, mimicking inflammation of another origin. However, little is known about the pathogenesis of the disease, as patients are seldom suspected and rarely diagnosed with lymphocytic esophagitis. Case presentation Here, we present a rare case of lymphocytic esophagitis in a patient with multiple allergies and suspected eosinophilic esophagitis. A 28-year-old woman with polyvalent sensitization to food and inhalant allergens presented with intermittent dysphagia, a sensation of a foreign body in the throat, itchiness of the oral cavity after ingesting certain foods, heartburn, and prolonged chewing time. A skin prick test showed positive results for birch-tree, alder, hazel, and rye pollen, as well as house dust mites. Apart from obesity (BMI 30 kg/m2), multiple pustules and excoriations on the skin, her physical examination was insignificant. Esophagogastroduodenoscopy (EGD) was performed revealing full-length but discrete trachealization of the esophagus. A barium swallow test showed slowing of esophageal peristalsis in the recumbent position. No esophageal pathology was observed. A histopathological analysis of mucosal samples revealed slight hyperplasia of the basal layer of the esophagus, and the stomach showed changes typical of chronic gastritis. Conclusions In summary, this clinical case illustrates that lymphocytic esophagitis, as a newly recognized entity, should be considered in the differential diagnosis of chronic dysphagia. Additionally, when treating allergic patients, clinicians should be aware that lymphocytic esophagitis, distinct from eosinophilic esophagitis, should be considered in the diagnosis of patients with atopy and upper gastrointestinal symptoms.
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Affiliation(s)
- O Wojas
- Department of Prevention of Environmental Hazard and Allergology, Medical University of Warsaw, Warsaw, Poland
| | - M Żalikowska-Gardocka
- Department of Gastroenterology and Internal Medicine, Medical University of Warsaw, Warsaw, Poland.
| | - E Krzych-Fałta
- Department of Prevention of Environmental Hazard and Allergology, Medical University of Warsaw, Warsaw, Poland
| | - B Szczepankiewicz
- Department of Pathomorphology, Medical University of Warsaw, Warsaw, Poland
| | - P Samel-Kowalik
- Department of Prevention of Environmental Hazard and Allergology, Medical University of Warsaw, Warsaw, Poland
| | - B Samoliński
- Department of Prevention of Environmental Hazard and Allergology, Medical University of Warsaw, Warsaw, Poland
| | - A Przybyłkowski
- Department of Gastroenterology and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
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Talley NJ, Zand Irani M. Optimal management of severe symptomatic gastroesophageal reflux disease. J Intern Med 2021; 289:162-178. [PMID: 32691466 DOI: 10.1111/joim.13148] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 05/29/2020] [Indexed: 12/12/2022]
Abstract
Gastroesophageal reflux disease (GERD) is a common disorder, and empirical proton pump inhibitor (PPI) treatment is often the first step of management; however, up to 40% of patients remain symptomatic despite PPI treatment. Refractory reflux refers to continued symptoms despite an adequate trial of PPI, and management remains challenging. The differential diagnosis is important; other oesophageal (e.g. eosinophilic oesophagitis) and gastroduodenal disorders (e.g. functional dyspepsia) should be ruled out, as this changes management. A combination of clinical assessment, endoscopic evaluation and in selected cases oesophageal function testing can help characterize patients with refractory reflux symptoms into oesophageal phenotypes so appropriate therapy can be more optimally targeted. Medical options then may include adding a H2 receptor antagonist, alginates, baclofen or antidepressant therapy, and there is emerging evidence for bile acid sequestrants and diaphragmatic breathing. The demonstration of a temporal association of symptoms with reflux events on pH-impedance testing (reflux hypersensitivity) serves to focus the management on modulating oesophageal perception and reducing the reflux burden, or identifies those with no obvious pathophysiologic abnormalities (functional heartburn). Anti-reflux surgery based on randomized controlled trial evidence has a role in reflux hypersensitivity or continued pathological acid reflux despite PPI in carefully considered, fully worked up cases that have failed medical therapy; approximately two of three cases will respond but there is a small risk of complications. In patients with persistent volume reflux despite medical therapy, given the lack of alternatives, anti-reflux surgery is a consideration. Promising newer approaches include endoscopic techniques. This review aims to summarize current diagnostic approaches and critically evaluates the evidence for the efficacy of available treatments.
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Affiliation(s)
- N J Talley
- From the, NHMRC Centre of Research Excellence of Digestive Health, Faculty of Health and Medicine, University of Newcastle, New Lambton Heights, NSW, Australia.,Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
| | - M Zand Irani
- From the, NHMRC Centre of Research Excellence of Digestive Health, Faculty of Health and Medicine, University of Newcastle, New Lambton Heights, NSW, Australia.,Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
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Resende F, Ferrão A, Melo R, Barbosa E, Barbosa A. A New Differential Diagnosis of Dysphagia: A Case Report of Lymphocytic Esophagitis. Cureus 2021; 13:e13010. [PMID: 33659141 PMCID: PMC7920230 DOI: 10.7759/cureus.13010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Lymphocytic esophagitis is a rare but increasingly recognized cause of chronic esophagitis. The pathogenesis, prognosis, and treatment are undefined. We report the diagnostic workup of an unusual cause of dysphagia. We present a case report of a 71-year-old female who presented with dysphagia for solid foods. The endoscopic appearance showed stenosis at the cricopharyngeus and trachealization of the proximal esophagus. Biopsies were taken to exclude eosinophilic esophagitis. The pathology showed lymphocytic infiltrate with peripapillary distribution with no granulocytes and spongiosis suggestive of lymphocytic esophagitis. Esomeprazol was started with symptomatic improvement. The symptoms and endoscopic appearance of lymphocytic esophagitis may be indistinguishable from other forms of chronic esophagitis. A high index of suspicion and mucosal sampling are essential to establish the diagnosis. Lymphocytic esophagitis seems to be a chronic and benign form of esophagitis. It should be included in the differential diagnosis of dysphagia. Further research and case reporting are essential to better define its pathogenesis, prognosis, and treatment.
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Affiliation(s)
- Fernando Resende
- General Surgery, Centro Hospitalar e Universitário de São João, Porto, PRT
| | - António Ferrão
- General Surgery, Centro Hospitalar e Universitário de São João, Porto, PRT
| | - Renato Melo
- General Surgery, Centro Hospitalar e Universitário de São João, Porto, PRT
| | - Elisabete Barbosa
- General Surgery, Centro Hospitalar e Universitário de São João, Porto, PRT
| | - Adelino Barbosa
- General Surgery, Centro Hospitalar e Universitário de São João, Porto, PRT
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Abstract
Although the features of lower gastrointestinal tract inflammation associated with ulcerative colitis and Crohn disease are generally familiar to pathologists, there is less awareness of and familiarity with the manifestations of inflammatory bowel disease in the esophagus, stomach, and duodenum. Nonetheless, their diagnosis has therapeutic and possibly prognostic implications, potentially foretelling severe complications. The recognition that ulcerative colitis can affect gastrointestinal organs proximal to the large intestine and terminal ileum represents a revision of concepts ingrained among generations of physicians. This article reviews the pathologic features and clinical significance of esophagitis, gastritis, and duodenitis associated with inflammatory bowel disease.
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Affiliation(s)
- Noam Harpaz
- Department of Pathology, Molecular and Cell-Based Medicine, Icahn School of Medicine at Mount Sinai, Annenberg Building Room 15-38, 1468 Madison Avenue, New York, NY 10029, USA; Department of Medicine, Icahn School of Medicine at Mount Sinai, Annenberg Building Room 15-38, 1468 Madison Avenue, New York, NY 10029, USA.
| | - Alexandros D Polydorides
- Department of Pathology, Molecular and Cell-Based Medicine, Icahn School of Medicine at Mount Sinai, Annenberg Building Room 15-38, 1468 Madison Avenue, New York, NY 10029, USA; Department of Medicine, Icahn School of Medicine at Mount Sinai, Annenberg Building Room 15-38, 1468 Madison Avenue, New York, NY 10029, USA
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