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Hussein M, Mitchison M, Sweis R. Lymphocytic oesophagitis: diagnosis and management. Clin Med (Lond) 2023; 23:540-544. [PMID: 38065611 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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2
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Hentschel F. Chronic fibrosing esophagitis with diffuse esophageal intramural pseudo‐diverticulosis. JGH OPEN 2022; 6:287-291. [PMID: 35601128 PMCID: PMC9120889 DOI: 10.1002/jgh3.12750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 03/24/2022] [Accepted: 04/23/2022] [Indexed: 12/01/2022]
Abstract
Diffuse esophageal intramural pseudo‐diverticulosis (DEIPD) is a chronic fibrosing inflammation of the esophagus of unknown origin. Its name derives from the characteristic pseudo‐diverticula formed by dilated ducts of submucosal glands. With an assumed prevalence of approximately 5–50/100 000, DEIPD is more frequent than previously estimated. It preferentially affects men between 50 and 70 years of age with a history of alcohol and tobacco abuse. Key symptoms are chronic dysphagia and food impactions. Typical endoscopic findings are multiple small, longitudinally aligned pseudo‐diverticle openings and trachealization of the esophagus. Additionally, the usually gray mucosa may show a fine‐grained pattern of very small red dots that merge into a pink tint, called “faux uni pattern.” Once established, clinical symptoms and endoscopic changes persist throughout life. Although there is no known causal therapy, complications like bolus impactions, candida infections, or reflux can and should be treated.
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Affiliation(s)
- Florian Hentschel
- Department of Gastroenterology and Hepatology Brandenburg Medical School (Theodor Fontane) Brandenburg Germany
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3
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Abstract
This review summarizes our current understanding of lymphocytic esophagitis (LE), a novel form of chronic esophagitis that incorporates distinctive histologic, clinical, and endoscopic features. First described as a histologic entity, a diagnosis of LE requires intraepithelial lymphocytosis without significant granulocytic inflammation and some evidence of epithelial damage; the rationale for and studies supportive of these histologic criteria are discussed within. Clinically, the majority of patients who present with histologically confirmed LE are older women or patients with underlying immunologic abnormalities, such as Crohn disease, rheumatologic disorders, or common variable immunodeficiency. The most common presenting symptom of LE is dysphagia, and the endoscopic findings can vary from normal mucosa to mucosal changes that resemble eosinophilic esophagitis: edema, rings, furrows, and plaques. The incidence of luminal strictures and the persistent dysphagia and/or lymphocytosis present in some patients provide evidence that LE is a chronic inflammatory disorder, at least within a subset of individuals. Several histologic mimics of LE are examined, as are disagreements surrounding the LE diagnosis.
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4
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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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5
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Lin J, Liu G, Duan Z. The mechanism of esophagus dysmotility in diabetes and research progress of relating treatments. Expert Rev Gastroenterol Hepatol 2021; 15:919-927. [PMID: 34156876 DOI: 10.1080/17474124.2021.1945921] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: Esophagus dysmotility is a crucial risk factor of gastroesophageal reflux disease (GERD), which is one of the most common diseases in digestive medicine globally. This review emphasizes the mechanisms of esophagus dysmotility in diabetes and summarizes more targeted treatments for these patients to avoid the overuse of proton pump inhibitors (PPIs).Areas covered: Diabetes mellitus (DM) is a clear factor that must not be neglected in the development of GERD. Previous studies have preliminarily researched the esophagus deterioration in diabetes. However, the multi-faceted mechanisms of esophagus dysmotility in diabetes need more studies. Besides, targeted treatments for these patients rather than conventional PPIs are urgently needed.Expert opinion: The treatments for GERD patients with diabetes should be further explored. Pharmacological approaches such as prokinetic agents, psychotherapy can be adopted. Meanwhile, it's feasible to explore non-drug treatments. For example, Electroacupuncture (EA) at Zusanli (ST-36) may be effective to protect the networks of intestinal cells of Cajal (ICCs) in diabetes. More effective approaches should be explored to achieve individualized treatment for these patients.
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Affiliation(s)
- Jiarong Lin
- The Second Department of Gastroenterology, The First Affiliated Hospital of Dalian Medical University, Dalian, China.,Laboratory of Integrated Chinese and Western Medicine, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Gongkai Liu
- School of Medicine, Nova Southeastern University, Davie, FL, USA
| | - Zhijun Duan
- The Second Department of Gastroenterology, The First Affiliated Hospital of Dalian Medical University, Dalian, China.,Laboratory of Integrated Chinese and Western Medicine, The First Affiliated Hospital of Dalian Medical University, Dalian, China
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Muller K, Xiao J, Putra J, Rothstein R, McCourt C, Konnikova L, Lisovsky M. Lymphocytic Esophagitis With Predominance of CD4 T Cells and Expansion of Th1 Cells Is Associated With Achalasia. Am J Clin Pathol 2021; 156:278-287. [PMID: 33609026 DOI: 10.1093/ajcp/aqaa239] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Although histologic features in biopsies suggesting a possibility of achalasia would be helpful diagnostically, such features remain unknown. The goal of this study was to explore the prevalence, histologic features, and immunophenotype of lymphocytic esophagitis (LyE) in achalasia biopsies. METHODS The study group consisted of 57 patients with achalasia. Controls comprised 52 patients with severe gastroesophageal reflux disease (GERD) and normal esophageal motility. CD4/CD8 immunophenotype of lymphocytes was analyzed by immunohistochemistry. RESULTS LyE was identified in 30% (17/57) of patients with achalasia and 6% (3/52) of patients with GERD, indicating a strong association with achalasia (odds ratio, 6.94; 95% confidence interval, 1.90-25.38). LyE was focal in 59% (10/17) of the cases and diffuse in 41% (7/17). CD4 T-cell predominance over CD8 T cells was observed in 88% of patients with achalasia and LyE. T helper 1 (Th1) cells, but not T helper 2 cells, were expanded in CD4 T cells; in the absence of evident infection, this was compatible with the role of Th1 cells in organ-specific autoimmunity. CONCLUSIONS Achalasia should be considered in the differential diagnosis of clinical entities associated with CD4-predominant LyE. Additional studies to explore the significance of Th1 cells in achalasia-associated LyE are warranted.
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Affiliation(s)
- Kristen Muller
- Department of Pathology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Jenny Xiao
- Department of Pediatrics, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Juan Putra
- Department of Pathology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Richard Rothstein
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Collin McCourt
- Department of Pediatrics, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Liza Konnikova
- Department of Pediatrics, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA
- Department of Immunology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Mikhail Lisovsky
- Department of Pathology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
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7
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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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8
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Hypercontractile Esophagus From Pathophysiology to Management: Proceedings of the Pisa Symposium. Am J Gastroenterol 2021; 116:263-273. [PMID: 33273259 DOI: 10.14309/ajg.0000000000001061] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 10/22/2020] [Indexed: 12/11/2022]
Abstract
Hypercontractile esophagus (HE) is a heterogeneous major motility disorder diagnosed when ≥20% hypercontractile peristaltic sequences (distal contractile integral >8,000 mm Hg*s*cm) are present within the context of normal lower esophageal sphincter (LES) relaxation (integrated relaxation pressure < upper limit of normal) on esophageal high-resolution manometry (HRM). HE can manifest with dysphagia and chest pain, with unclear mechanisms of symptom generation. The pathophysiology of HE may entail an excessive cholinergic drive with temporal asynchrony of circular and longitudinal muscle contractions; provocative testing during HRM has also demonstrated abnormal inhibition. Hypercontractility can be limited to the esophageal body or can include the LES; rarely, the process is limited to the LES. Hypercontractility can sometimes be associated with esophagogastric junction (EGJ) outflow obstruction and increased muscle thickness. Provocative tests during HRM can increase detection of HE, reproduce symptoms, and predict delayed esophageal emptying. Regarding therapy, an empiric trial of a proton pump inhibitor, should be first considered, given the overlap with gastroesophageal reflux disease. Calcium channel blockers, nitrates, and phosphodiesterase inhibitors have been used to reduce contraction vigor but with suboptimal symptomatic response. Endoscopic treatment with botulinum toxin injection or pneumatic dilation is associated with variable response. Per-oral endoscopic myotomy may be superior to laparoscopic Heller myotomy in relieving dysphagia, but available data are scant. The presence of EGJ outflow obstruction in HE discriminates a subset of patients who may benefit from endoscopic treatment targeting the EGJ.
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9
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Malone V, Sheahan K. Novel and rare forms of oesophagitis. Histopathology 2020; 78:4-17. [PMID: 33382498 DOI: 10.1111/his.14284] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 10/09/2020] [Accepted: 10/20/2020] [Indexed: 12/11/2022]
Abstract
Our understanding of inflammatory diseases of the gastrointestinal tract, including those of the oesophagus, has expanded in recent years. Once attributed almost exclusively to gastro-oesophageal reflux disease or infection, it is now recognised that oesophagitis may occur due to a variety of distinct disease entities. Many of these conditions cause debilitating and persistent symptoms, impacting upon quality of life and necessitating ongoing surveillance and treatment. This review will consider the clinical, endoscopic and histopathological features of these novel and rare forms of oesophagitis.
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Affiliation(s)
- Victoria Malone
- Department of Histopathology, St Vincent's University Hospital, School of Medicine and Medical Science, University College Dublin, Dublin, Ireland
| | - Kieran Sheahan
- Department of Histopathology, St Vincent's University Hospital, School of Medicine and Medical Science, University College Dublin, Dublin, Ireland
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10
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Moiseff R, Olson N, Suriawinata AA, Rothstein RI, Lisovsky M. CD8 T-Cell-Predominant Lymphocytic Esophagitis is One of the Major Patterns of Lymphocytic Inflammation in Gastroesophageal Reflux Disease. Arch Pathol Lab Med 2020; 145:1138-1143. [PMID: 33373450 DOI: 10.5858/arpa.2020-0430-oa] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/30/2020] [Indexed: 11/06/2022]
Abstract
CONTEXT.— Published reports have suggested an association of lymphocytic esophagitis (LyE) with gastroesophageal reflux disease (GERD) and primary motility disorders and have also shown that GERD and motility disorders frequently overlap. These findings make it difficult to determine the true relationship between LyE and GERD, which may be confounded by the presence of motility disorders with LyE. OBJECTIVE.— To characterize patterns of lymphocytic inflammation in patients with GERD that have no motility abnormalities. DESIGN.— We identified 161 patients seen at our institution from 1998 to 2014, who were diagnosed with GERD, had normal esophageal motility, and available esophageal biopsies. LyE was defined as peripapillary lymphocytosis with rare or absent granulocytes. CD4 and CD8 immunophenotype of lymphocytes was evaluated using immunohistochemistry. RESULTS.— We found increased intraepithelial lymphocytes in 13.7% of patients with GERD. Two major patterns and 1 minor pattern of lymphocytic inflammation were observed as follows: (1) LyE (in 6.8% [11 of 161] of patients and typically focal), (2) dispersed lymphocytes in an area of reflux esophagitis (in 5.6% [9 of 161] and typically diffuse), and (3) peripapillary lymphocytes in an area of reflux esophagitis (in 1.2% [2 of 161]). CD8 T cells significantly outnumbered CD4 T cells in 91% of patients with lymphocytic esophagitis and 100% of patients with dispersed lymphocytes (9 of 9) or peripapillary lymphocytes (2 of 2) in the area of reflux esophagitis. CONCLUSIONS.— These findings suggest that LyE is one of the major patterns of lymphocytic inflammation in GERD. CD8 T-cell-predominant immunophenotype may be useful as a marker of GERD in the differential diagnosis of LyE.
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Affiliation(s)
- Robin Moiseff
- From the Department of Pathology (Moiseff, Olson, Suriawinata, Lisovsky)
| | - Nicholas Olson
- From the Department of Pathology (Moiseff, Olson, Suriawinata, Lisovsky).,Olson is currently located at Physicians Laboratory in Sioux Falls, South Dakota
| | | | - Richard I Rothstein
- and Section of Gastroenterology and Hepatology (Rothstein), at Dartmouth-Hitchcock Medical Center and Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Mikhail Lisovsky
- From the Department of Pathology (Moiseff, Olson, Suriawinata, Lisovsky)
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11
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Savarino E, Smout AJPM. The hypercontractile esophagus: Still a tough nut to crack. Neurogastroenterol Motil 2020; 32:e14010. [PMID: 33043556 PMCID: PMC7685127 DOI: 10.1111/nmo.14010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 09/21/2020] [Accepted: 09/21/2020] [Indexed: 12/26/2022]
Abstract
Hypercontractile esophagus (HE), also known as jackhammer esophagus, is an esophageal motility disorder. Nowadays, high-resolution manometry (HRM) is used to diagnose the disorder. According to the latest iteration of the Chicago classification, HE is present when at least 2 out 10 liquid swallow-induced peristaltic waves have an abnormally high Distal Contractile Integral. In the era of conventional manometry, a similar condition, referred to as nutcracker esophagus, was diagnosed when the peristaltic contractions had an abnormally high mean amplitude. Although the HRM diagnosis of HE is relatively straight-forward, effective management of the disorder is challenging as the correlation with symptoms is variable and treatment effects are dubious. In this mini-review, we discuss the most troublesome uncertainties that still surround HE, in the light of new data on etiology and epidemiology published in this issue of Neurogastroenterology and Motility.
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Affiliation(s)
- Edoardo Savarino
- Department of Surgery, Oncology and GastroenterologyUniversity of PaduaPaduaItaly
| | - André J. P. M. Smout
- Department of Gastroenterology and HepatologyAmsterdam University Medical CentersAmsterdamThe Netherlands
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12
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Lisovsky M. Inflammatory conditions of the esophagus: an update. Ann N Y Acad Sci 2020; 1481:5-10. [PMID: 32783223 DOI: 10.1111/nyas.14450] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 07/06/2020] [Accepted: 07/08/2020] [Indexed: 12/24/2022]
Abstract
A variety of inflammatory disorders involve the esophagus. This commentary discusses the pathology of some forms of esophagitis, with an emphasis on recent developments. The initial section focuses on some common forms of nonreflux esophagitis, including lymphocytic esophagitis and eosinophilic esophagitis. Recent studies suggest that lymphocytic esophagitis may be associated with esophageal motility disorders and gastroesophageal reflux disease. Immunophenotypic features of intraepithelial lymphocytes may be helpful in distinguishing these conditions. Updates on the criteria and the limitations of histologic approach to the diagnosis of eosinophilic esophagitis are presented and new diagnostic adjuncts are discussed. In the remaining section, novel entities, such as IgG4-related esophagitis, are discussed. IgG4-related esophagitis has been recognized as a cause of esophageal lymphoplasmacytic inflammation. Increased understanding of esophageal inflammation remains an important goal that likely will lead to new approaches in the therapy of inflammatory esophageal diseases.
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Affiliation(s)
- Mikhail Lisovsky
- Department of Pathology, Dartmouth-Hitchcock Medical Center and Geisel Medical School at Dartmouth, Lebanon, New Hampshire
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13
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Zheng H, Iyer RS, Pacheco MC, Soares JJ, Johnson K, Len M, Ambartsumyan L. Respiratory infections and chronic cough due to triple A (Allgrove) syndrome. Clin Case Rep 2020; 8:437-440. [PMID: 32185032 PMCID: PMC7069866 DOI: 10.1002/ccr3.2683] [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] [Received: 08/15/2019] [Revised: 10/31/2019] [Accepted: 11/18/2019] [Indexed: 11/29/2022] Open
Abstract
Cough and respiratory infections are common in pediatrics. Our case report illustrates the need for pediatricians to consider rare diagnoses such as genetic syndromes and primary gastrointestinal motility disorders in patients with unremitting respiratory and gastrointestinal symptoms. Early identification provides early intervention and reduces long-term morbidity for pediatric patients.
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Affiliation(s)
- Hengqi Zheng
- Division of GastroenterologySeattle Children's HospitalSeattleWashington
| | - Ramesh S. Iyer
- Department of RadiologySeattle Children's HospitalSeattleWashington
| | | | | | - Kaalan Johnson
- Department of OtolaryngologySeattle Children's HospitalSeattleWashington
| | - Mary Len
- Division of GastroenterologySeattle Children's HospitalSeattleWashington
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14
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[Lymphocytic oesophagitis: A rare emerging cause of food impaction]. Semergen 2020; 46:286-288. [PMID: 31964566 DOI: 10.1016/j.semerg.2019.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 11/05/2019] [Accepted: 11/08/2019] [Indexed: 11/22/2022]
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15
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16
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Esophagitis in patients without gastroesophageal reflux disease or eosinophilic esophagitis: diagnostic considerations. Curr Opin Gastroenterol 2019; 35:379-386. [PMID: 33216485 DOI: 10.1097/mog.0000000000000539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
PURPOSE OF REVIEW A multitude of inflammatory diseases other than gastroesophageal reflux disease (GERD) and eosinophilic esophagitis can affect the esophagus. Despite the deceptively simple organization of squamous mucosa and its limited number of inflammatory responses, a wide array of histologic patterns can be seen in inflammatory disorders involving the esophagus. Each such histologic pattern is associated with a limited number of underlying conditions, and the clinician can use this information to narrow the differential diagnosis. The purpose of this review is to review and discuss the pathologic diagnosis of esophagitis caused by conditions other than GERD or eosinophilic esophagitis, with an emphasis on recent developments in the field. RECENT FINDINGS Recent studies suggest that lymphocytic esophagitis may be a histologic manifestation of esophageal motility disorders. Immunophenotypic features of infiltrating lymphocytes may be helpful in this scenario. immunoglobulin G4-related disease has been implicated as a cause of esophageal inflammation with ulceration, strictures, and mass-forming fibrosis, whereas epidermoid metaplasia has been linked molecularly to the squamous cell neoplasia pathway. SUMMARY Improved knowledge and appreciation of the pathology of esophageal inflammation are needed to better understand the pathogenesis of various types of esophagitis, and to inform new approaches to the therapy and management of inflammatory esophageal diseases.
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Abuquteish D, Putra J. Upper gastrointestinal tract involvement of pediatric inflammatory bowel disease: A pathological review. World J Gastroenterol 2019; 25:1928-1935. [PMID: 31086461 PMCID: PMC6487385 DOI: 10.3748/wjg.v25.i16.1928] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 04/03/2019] [Accepted: 04/10/2019] [Indexed: 02/06/2023] Open
Abstract
Upper gastrointestinal (UGI) tract involvement of inflammatory bowel disease (IBD) is commonly seen in pediatric patients. Upper endoscopy is included in the routine workup of children with suspected IBD to enhance the diagnosis and management of these patients. Currently, childhood IBD is classified into ulcerative colitis (UC), atypical UC, Crohn’s disease (CD) and IBD unclassified. Histologic confirmation of UGI tract involvement, in particular the presence of epithelioid (non-caseating) granulomas, is helpful in confirming the diagnosis of IBD and its classification. Herein, we reviewed selected IBD-associated UGI tract manifestations in children. Lymphocytic esophagitis, seen predominantly in CD, is histologically characterized by increased intraepithelial lymphocytes (> 20 in one high-power field) in a background of mucosal injury with absence of granulocytes. Focally enhanced gastritis is a form of gastric inflammation in pediatric IBD marked by a focal lymphohistiocytic pit inflammation with or without granulocytes and plasma cells in a relatively normal background gastric mucosa. Duodenal inflammation seen in children with IBD includes cryptitis, villous flattening, increased intraepithelial lymphocytes, and lamina propria eosinophilia. Finally, epithelioid granulomas not associated with ruptured gland/crypt are a diagnostic feature of CD. The clinicopathologic correlation and differential diagnosis of each microscopic finding are discussed. Clinicians and pathologists should be cognizant of the utility and limitations of these histologic features.
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Affiliation(s)
- Dua Abuquteish
- Division of Pathology, Department of Paediatric Laboratory Medicine, Hospital for Sick Children, Toronto, ON M5G 1X8, Canada
| | - Juan Putra
- Division of Pathology, Department of Paediatric Laboratory Medicine, Hospital for Sick Children, Toronto, ON M5G 1X8, Canada
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18
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Zikos TA, Clarke JO, Triadafilopoulos G, Regalia KA, Sonu IS, Fernandez-Becker NQ, Nandwani MC, Nguyen LA. A Positive Correlation Between Gastric and Esophageal Dysmotility Suggests Common Causality. Dig Dis Sci 2018; 63:3417-3424. [PMID: 29946871 DOI: 10.1007/s10620-018-5175-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 06/19/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND Gastric and esophageal dysmotility syndromes are some of the most common motility diagnoses, but little is known about their interrelationship. AIMS The aim of our study was to determine if a correlation exists between gastric and esophageal dysmotility syndromes. METHODS We reviewed the records of all patients who underwent both solid gastric emptying scintigraphy (GES) and high-resolution esophageal manometry (HRM) within a 2 year period, with both done between August 2012 and August 2017. All GESs were classified as either rapid, normal, or delayed. All HRMs were classified according to the Chicago Classification 3.0. Correlations were assessed using Fisher's exact test and multiple logistic regression. RESULTS In total, 482 patients met inclusion criteria. Of patients with a normal, delayed, and rapid GES, 53.1, 64.5, and 77.3% had an abnormal HRM, respectively (p < 0.05 vs. normal GES). Likewise, patients with an abnormal HRM were more likely to have an abnormal GES (54.9 vs. 41.8%, p = 0.005). Multiple logistic regression showed abnormal GES [odds ratio (OR) 2.14], age (OR 1.013), scleroderma (OR 6.29), and dysphagia (OR 2.63) were independent predictors of an abnormal HRM. Likewise, an abnormal HRM (OR 2.11), diabetes (OR 1.85), heart or lung transplantation (OR 2.61), and autonomic dysfunction (OR 2.37) were independent predictors of an abnormal GES. CONCLUSIONS The correlation between an abnormal GES and HRM argues for common pathogenic mechanisms of these motility disorders, and possibly common future treatment options. Clinicians should have a high index of suspicion for another motility disorder if one is present.
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Affiliation(s)
- Thomas A Zikos
- Stanford Multidimensional Program for Innovation and Research in the Esophagus (S-MPIRE), Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 300 Pasteur Drive, Alway Building, Room M211, Stanford, CA, 94305-5187, USA.
| | - John O Clarke
- Stanford Multidimensional Program for Innovation and Research in the Esophagus (S-MPIRE), Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 300 Pasteur Drive, Alway Building, Room M211, Stanford, CA, 94305-5187, USA
| | - George Triadafilopoulos
- Stanford Multidimensional Program for Innovation and Research in the Esophagus (S-MPIRE), Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 300 Pasteur Drive, Alway Building, Room M211, Stanford, CA, 94305-5187, USA
| | - Kirsten A Regalia
- Stanford Multidimensional Program for Innovation and Research in the Esophagus (S-MPIRE), Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 300 Pasteur Drive, Alway Building, Room M211, Stanford, CA, 94305-5187, USA
| | - Irene S Sonu
- Stanford Multidimensional Program for Innovation and Research in the Esophagus (S-MPIRE), Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 300 Pasteur Drive, Alway Building, Room M211, Stanford, CA, 94305-5187, USA
| | - Nielsen Q Fernandez-Becker
- Stanford Multidimensional Program for Innovation and Research in the Esophagus (S-MPIRE), Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 300 Pasteur Drive, Alway Building, Room M211, Stanford, CA, 94305-5187, USA
| | - Monica C Nandwani
- Stanford Multidimensional Program for Innovation and Research in the Esophagus (S-MPIRE), Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 300 Pasteur Drive, Alway Building, Room M211, Stanford, CA, 94305-5187, USA
| | - Linda A Nguyen
- Stanford Multidimensional Program for Innovation and Research in the Esophagus (S-MPIRE), Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 300 Pasteur Drive, Alway Building, Room M211, Stanford, CA, 94305-5187, USA
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19
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Mucosal inflammation in Candida esophagitis has distinctive features that may be helpful diagnostically. Mod Pathol 2018; 31:1653-1660. [PMID: 29921901 DOI: 10.1038/s41379-018-0060-4] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Revised: 02/28/2018] [Accepted: 03/24/2018] [Indexed: 12/13/2022]
Abstract
The diagnosis of Candida esophagitis can be challenging when the epithelium containing Candida filamentous forms is not readily seen or is entirely sloughed away. Mucosal inflammation could be helpful diagnostically, if distinctive. However it is thought to be nonspecific in Candida esophagitis. The goal of this retrospective study was to identify features of mucosal inflammation helpful in alerting a pathologist to the possibility of Candida esophagitis when Candida mycelia are not readily observed. The study group consisted of 99 consecutive cases of Candida esophagitis and a control group of 64 consecutive cases of reflux esophagitis diagnosed at our institution from 2008-2016. Band-like superficial intraepithelial neutrophils and increased intraepithelial lymphocytes were observed in 75 and 67% of Candida esophagitis cases, respectively and only in 14 and 19% of reflux esophagitis cases, respectively (p < .0001). Intraepithelial lymphocytes were peripapillary or CD4-predominant in 75% of Candida esophagitis cases with increased lymphocytes, in contrast to 17% of reflux esophagitis cases (p = .0011). Concurrent presence of intraepithelial neutrophils and increased lymphocytes showed increased specificity for Candida esophagitis and was observed in 61% of patients with Candida esophagitis and only in 2% of patients with reflux esophagitis (p < .0001). In addition, superficial band-like neutrophils were observed concurrently with increased peripapillary lymphocytes or CD4-predominant lymphocytes in 35 and 50% of Candida esophagitis cases, respectively, in contrast to no reflux esophagitis cases. Basal cell hyperplasia and elongation of stromal papillae were frequent in both groups. The data suggest that when Candida microorganisms are not readily observed, concurrent presence of superficial band-like neutrophils and increased lymphocytes may be indicative of Candida etiology of active esophagitis.
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Patil DT, Hammer S, Langer R, Yantiss RK. Lymphocytic esophagitis: an update on histologic diagnosis, endoscopic findings, and natural history. Ann N Y Acad Sci 2018; 1434:185-191. [PMID: 29797752 DOI: 10.1111/nyas.13710] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 03/11/2018] [Accepted: 03/14/2018] [Indexed: 12/14/2022]
Abstract
Lymphocytic esophagitis is a histologic pattern of injury characterized by increased intraepithelial lymphocytes (>20/high-power field) with rare, or absent granulocytes. Lymphocytes tend to be more numerous in the peripapillary epithelium, and are often associated with evidence of mucosal injury, edema, and scattered dyskeratotic cells. More than a decade following its original description, lymphocytic esophagitis remains an enigmatic entity with variable clinical presentations, associated disorders, etiologies, treatment, and natural history. Most of the confusion regarding the clinical significance of this disorder stems from its diagnostic criteria: lymphocytic esophagitis is currently defined based entirely on histologic criteria, despite the common occurrence of lymphocytosis in a variety of unrelated inflammatory conditions of the esophagus. The goal of this review is to summarize the literature regarding lymphocytic esophagitis and focus on key clinicopathologic features that distinguish it from other esophageal disorders that can show increased numbers of intraepithelial lymphocytes.
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Affiliation(s)
- Deepa T Patil
- Department of Pathology, Cleveland Clinic, Lerner College of Medicine, Cleveland, Ohio
| | - Suntrea Hammer
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Rupert Langer
- Institute of Pathology, University of Bern, Bern, Switzerland
| | - Rhonda K Yantiss
- Department of Pathology and Laboratory Medicine, Weill Cornell Medical College, New York, New York
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21
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Panarelli NC. Other Forms of Esophagitis: It Is Not Gastroesophageal Reflux Disease, So Now What Do I Do? Surg Pathol Clin 2017; 10:765-779. [PMID: 29103532 DOI: 10.1016/j.path.2017.07.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Esophagitis results from diverse causes, including gastroesophageal reflux, immune-mediated or allergic reactions, therapeutic complications, and infections. The appropriate clinical management differs in each of these situations and is often guided by pathologic interpretation of endoscopic mucosal biopsy specimens. This review summarizes the diagnostic features of unusual forms of esophagitis, including eosinophilic esophagitis, lymphocytic esophagitis, esophagitis dissecans superficialis, drug-induced esophageal injury, and bullous disorders. Differential diagnoses and distinguishing features are emphasized.
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Affiliation(s)
- Nicole C Panarelli
- Department of Pathology, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY 10467, USA.
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Johncilla ME, Srivastava A. Esophagitis unrelated to reflux disease: current status and emerging diagnostic challenges. Virchows Arch 2017; 472:29-41. [DOI: 10.1007/s00428-017-2238-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Revised: 09/18/2017] [Accepted: 09/20/2017] [Indexed: 02/07/2023]
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Rouphael C, Gordon IO, Thota PN. Lymphocytic esophagitis: Still an enigma a decade later. World J Gastroenterol 2017; 23:949-956. [PMID: 28246468 PMCID: PMC5311104 DOI: 10.3748/wjg.v23.i6.949] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Revised: 12/14/2016] [Accepted: 01/18/2017] [Indexed: 02/06/2023] Open
Abstract
Lymphocytic esophagitis (LE) is a clinicopathologic entity first described by Rubio et al in 2006. It is defined as peripapillary intraepithelial lymphocytosis with spongiosis and few or no granulocytes on esophageal biopsy. This definition is not widely accepted and the number of lymphocytes needed to make the diagnosis varied in different studies. Multiple studies have described potential clinical associations and risk factors for LE, such as old age, female gender and smoking history. This entity was reported in inflammatory bowel disease in the pediatric population but not in adults. Other associations include gastroesophageal reflux disease and primary esophageal motility disorders. The most common symptom is dysphagia, with a normal appearing esophagus on endoscopy, though esophageal rings, webs, nodularities, furrows and strictures have been described. Multiple treatment modalities have been used such as proton pump inhibitors and topical steroids. Esophageal dilation seems to be therapeutic when dysphagia is present along with esophageal narrowing secondary to webs, rings or strictures. The natural history of the disease remains unclear and needs to be better delineated. Overall, lymphocytic esophagitis seems to have a chronic and benign course, except for two cases of esophageal perforation in the literature, thought to be secondary to this entity.
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Gonzalez-Cordero PL, Rubio-Fernández A, Fernandez-Gonzalez N, Dueñas-Sadornil C, Molina-Infante J. Lymphocytic esophagitis: A rare finding in adult patients with dysphagia and food impaction. GASTROENTEROLOGIA Y HEPATOLOGIA 2017; 41:31-32. [PMID: 28089355 DOI: 10.1016/j.gastrohep.2016.11.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Accepted: 11/23/2016] [Indexed: 11/29/2022]
Affiliation(s)
| | | | | | - Carmen Dueñas-Sadornil
- Department of Gastroenterology, Hospital Universitario San Pedro de Alcantara, Caceres, Spain
| | - Javier Molina-Infante
- Department of Gastroenterology, Hospital Universitario San Pedro de Alcantara, Caceres, Spain
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25
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Lisovsky M, Westerhoff M, Zhang X. Lymphocytic esophagitis: a histologic pattern with emerging clinical ramifications. Ann N Y Acad Sci 2016; 1381:133-138. [PMID: 27635640 DOI: 10.1111/nyas.13260] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 08/22/2016] [Accepted: 08/23/2016] [Indexed: 02/05/2023]
Abstract
The clinical significance of lymphocytic esophagitis (LyE), which is characterized by the prominence of peripapillary intraepithelial lymphocytes (IELs) without significant granulocytosis, remains poorly understood. During the last few years, plausible clinical correlates and novel approaches for stratification of LyE have started to emerge. Association with Crohn's disease has been established in children, but is not observed in adults. In adults, the form of LyE showing CD4+ -predominant IELs has been recently found to be associated with non-achalasia primary motility abnormalities. GERD is another possible association. The most common clinical manifestations of adult LyE are dysphagia and normal endoscopic appearance of the esophagus. LyE should be reported by pathologists in order to distinguish it from its mimics, such as eosinophilic esophagitis, and to assist in directing the next steps in evaluation for known associated diseases, such as Crohn's disease or motility disorders.
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Affiliation(s)
- Mikhail Lisovsky
- Department of Pathology, Dartmouth-Hitchcock Medical Center and Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Maria Westerhoff
- Department of Anatomic Pathology, University of Washington School of Medicine, Seattle, Washington
| | - Xuchen Zhang
- Department of Pathology, Yale University School of Medicine, New Haven, Connecticut.
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