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Greuter T, Straumann A, Fernandez-Marrero Y, Germic N, Hosseini A, Chanwangpong A, Yousefi S, Simon D, Collins MH, Bussmann C, Chehade M, Dellon ES, Furuta GT, Gonsalves N, Hirano I, Moawad FJ, Biedermann L, Safroneeva E, Schoepfer AM, Simon HU. A Multicenter Long-Term Cohort Study of Eosinophilic Esophagitis Variants and Their Progression to Eosinophilic Esophagitis Over Time. Clin Transl Gastroenterol 2024; 15:e00664. [PMID: 38318864 PMCID: PMC11042771 DOI: 10.14309/ctg.0000000000000664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 11/06/2023] [Indexed: 02/07/2024] Open
Abstract
INTRODUCTION Eosinophilic esophagitis (EoE) variants have been recently characterized as conditions with symptoms of esophageal dysfunction resembling EoE, but absence of significant esophageal eosinophilia. Their disease course and severity have yet to be determined. METHODS Patients from 6 EoE centers with symptoms of esophageal dysfunction, but peak eosinophil counts of <15/hpf in esophageal biopsies and absence of gastroesophageal reflux disease with at least one follow-up visit were included. Clinical, (immuno)histological, and molecular features were determined and compared with EoE and healthy controls. RESULTS We included 54 patients with EoE variants (EoE-like esophagitis 53.7%; lymphocytic esophagitis 13.0%; and nonspecific esophagitis 33.3%). In 8 EoE-like esophagitis patients, EoE developed after a median of 14 months (interquartile range 3.6-37.6). Such progression increased over time (17.6% year 1, 32.0% year 3, and 62.2% year 6). Sequential RNA sequencing analyses revealed only 7 genes associated with this progression (with TSG6 and ALOX15 among the top 3 upregulated genes) with upregulation of a previously attenuated Th2 pathway. Immunostaining confirmed the involvement of eosinophil-associated proteins (TSG6 and ALOX15) and revealed a significantly increased number of GATA3-positive cells during progression, indicating a Th1/Th2 switch. Transition from one EoE variant (baseline) to another variant (during follow-up) was seen in 35.2% (median observation time of 17.3 months). DISCUSSION Transition of EoE variants to EoE suggests the presence of a disease spectrum. Few genes seem to be associated with the progression to EoE with upregulation of a previously attenuated Th2 signal. These genes, including GATA3 as a Th1/Th2 switch regulator, may represent potential therapeutic targets in early disease pathogenesis.
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Affiliation(s)
- Thomas Greuter
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland;
- Division of Gastroenterology and Hepatology, University Hospital Lausanne–Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland;
- GZO–Zurich Regional Health Center, Wetzikon, Switzerland;
| | - Alex Straumann
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland;
| | | | - Nina Germic
- Institute of Pharmacology, University of Bern, Bern, Switzerland;
| | - Aref Hosseini
- Institute of Pharmacology, University of Bern, Bern, Switzerland;
| | | | - Shida Yousefi
- Institute of Pharmacology, University of Bern, Bern, Switzerland;
| | - Dagmar Simon
- Department of Dermatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland;
| | - Margaret H. Collins
- Division of Pathology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Mirna Chehade
- Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Evan S. Dellon
- Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Glenn T. Furuta
- Department of Pediatrics, Gastrointestinal Eosinophilic Diseases Program, University of Colorado School of Medicine, Digestive Health Institute, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Nirmala Gonsalves
- Division of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois, USA
| | - Ikuo Hirano
- Division of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois, USA
| | - Fouad J. Moawad
- Division of Gastroenterology, Scripps Clinic, La Jolla Jolla, California, USA
| | - Luc Biedermann
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland;
| | - Ekaterina Safroneeva
- Insitute of Social and Preventive Medicine, University of Bern, Bern, Switzerland;
| | - Alain M. Schoepfer
- Division of Gastroenterology and Hepatology, University Hospital Lausanne–Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland;
| | - Hans-Uwe Simon
- Institute of Pharmacology, University of Bern, Bern, Switzerland;
- Institute of Biochemistry, Brandenburg Medical School, Neuruppin, Germany.
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Mitchell JM, Karamchandani DM. Histopathologic Manifestations of Immune Checkpoint Inhibitor Therapy-Associated Gastrointestinal Tract Injury: A Practical Review. Surg Pathol Clin 2023; 16:703-718. [PMID: 37863561 DOI: 10.1016/j.path.2023.05.007] [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: 10/22/2023]
Abstract
Immune checkpoint inhibitors have revolutionized the management of many advanced cancers by producing robust remissions. They mostly target two immune regulatory pathways: cytotoxic T lymphocyte antigen-4 and programmed death-1 or its ligand. However, a flip side is the immune-related adverse events (irAEs) commonly affecting the gastrointestinal (GI) tract that can cause treatment interruptions or discontinuation. This practical review discusses the clinical and histopathologic findings of irAEs encountered in the luminal GI tract, along with histopathologic differentials that can mimic varied inflammatory, infectious, or other medication-associated etiologies and the importance of clinico-pathologic correlation for an accurate diagnosis.
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Affiliation(s)
- James Michael Mitchell
- Department of Pathology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA. https://twitter.com/GIJamesMD
| | - Dipti M Karamchandani
- Department of Pathology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA.
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3
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Guenzi E, Poté N. [Lymphocytic "…itis", from esophagus to large bowel]. Ann Pathol 2023:S0242-6498(23)00032-9. [PMID: 36828723 DOI: 10.1016/j.annpat.2023.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 01/10/2023] [Accepted: 01/11/2023] [Indexed: 02/24/2023]
Abstract
Intra-epithelial lymphocytosis is an elementary lesion frequently observed in the gastrointestinal tract, which can be found from the esophagus to the colon. Many conditions of a varied nature (dysimmunitary diseases, drugs, infections…) are associated with intra-epithelial lymphocytosis, and the etiological diagnosis most often requires an anatomo-clinical correlation. The pathologist will have to identify histological lesions associated with intra-epithelial lymphocytosis allowing the diagnosis to be oriented in order to propose appropriate treatment. In this review, the main entities associated with digestive intra-epithelial lymphocytosis will be presented, detailing the key elements allowing their diagnosis.
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Affiliation(s)
- Edouard Guenzi
- Département de pathologie, hôpital Bichat, assistance publique-hôpitaux de Paris, 46, rue Henri-Huchard, 75018 Paris, France
| | - Nicolas Poté
- Département de pathologie, hôpital Bichat, assistance publique-hôpitaux de Paris, 46, rue Henri-Huchard, 75018 Paris, France.
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4
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Chatelain D, Moslemi A, Dreau A, Clement M. [Inflammatory bowel diseases and upper gastrointestinal tract]. Ann Pathol 2023:S0242-6498(22)00208-5. [PMID: 36822896 DOI: 10.1016/j.annpat.2022.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 12/05/2022] [Accepted: 12/06/2022] [Indexed: 02/23/2023]
Abstract
Inflammatory bowel diseases (IBD), Crohn's disease and ulcerative colitis are inflammatory diseases with a flare-up evolution and an unknown etiology. Inflammatory lesions of the upper gastrointestinal tract are more and more often described in Crohn's disease and ulcerative colitis. The aim of this article was to review the inflammatory lesions of the esophagus, stomach and duodenum currently described in the IBD.
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Affiliation(s)
- Denis Chatelain
- Service d'anatomie pathologie CHU Amiens, Place Victor-Pauchet, 80000 Amiens, France.
| | - Amine Moslemi
- Service d'anatomie pathologie CHU Amiens, Place Victor-Pauchet, 80000 Amiens, France
| | - Axel Dreau
- Service d'anatomie pathologie CHU Amiens, Place Victor-Pauchet, 80000 Amiens, France
| | - Marine Clement
- Service d'anatomie pathologie CHU Amiens, Place Victor-Pauchet, 80000 Amiens, France
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5
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Muacevic A, Adler JR, Liu SS, Dasaraju S. Pityriasis Lichenoides Chronica of Esophagus: A Rare Case Report. Cureus 2022; 14:e32290. [PMID: 36628008 PMCID: PMC9819751 DOI: 10.7759/cureus.32290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/26/2022] [Indexed: 12/13/2022] Open
Abstract
Pityriasis lichenoides chronica (PLC) is an uncommon inflammatory skin condition of unknown cause that ranges from a mild chronic form to a more severe acute eruption. Both forms usually involve the skin of the trunk and proximal extremities, and visceral involvement is not a well-described phenomenon. Here, we report a case of PLC that presented with esophageal involvement that occurred after a period of discontinuation of PLC treatment. The histological pattern of involvement is in the form of lymphocytic esophagitis, a non-specific pattern with a broad differential diagnosis. Awareness of the potential involvement of the esophagus and attention to certain endoscopic and morphological details may better help classify esophagitis biopsies and the diagnosis of this rare non-neoplastic chronic inflammatory disease. To our knowledge, this is the first-ever case of PLC with esophageal involvement, and nothing has been reported in the English literature earlier.
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Decker A, Schauer F, Lazaro A, Monasterio C, Schmidt AR, Schmitt-Graeff A, Kreisel W. Esophageal lichen planus: Current knowledge, challenges and future perspectives. World J Gastroenterol 2022; 28:5893-5909. [PMID: 36405107 PMCID: PMC9669830 DOI: 10.3748/wjg.v28.i41.5893] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 09/17/2022] [Accepted: 10/27/2022] [Indexed: 11/09/2022] Open
Abstract
Lichen planus (LP) is a frequent, chronic inflammatory disease involving the skin, mucous membranes and/or skin appendages. Esophageal involvement in lichen planus (ELP) is a clinically important albeit underdiagnosed inflammatory condition. This narrative review aims to give an overview of the current knowledge on ELP, its prevalence, pathogenesis, clinical manifestation, diagnostic criteria, and therapeutic options in order to provide support in clinical management. Studies on ELP were collected using PubMed/Medline. Relevant clinical and therapeutical characteristics from published patient cohorts including our own cohort were extracted and summarized. ELP mainly affects middle-aged women. The principal symptom is dysphagia. However, asymptomatic cases despite progressed macroscopic esophageal lesions may occur. The pathogenesis is unknown, however an immune-mediated mechanism is probable. Endoscopically, ELP is characterized by mucosal denudation and tearing, trachealization, and hyperkeratosis. Scarring esophageal stenosis may occur in chronic courses. Histologic findings include mucosal detachment, T-lymphocytic infiltrations, epithelial apoptosis (Civatte bodies), dyskeratosis, and hyperkeratosis. Direct immuno-fluorescence shows fibrinogen deposits along the basement membrane zone. To date, there is no established therapy. However, treatment with topical steroids induces symptomatic and histologic improvement in two thirds of ELP patients in general. More severe cases may require therapy with immunosuppressors. In symptomatic esophageal stenosis, endoscopic dilation may be necessary. ELP may be regarded as a precancerous condition as transition to squamous cell carcinoma has been documented in literature. ELP is an underdiagnosed yet clinically important differential diagnosis for patients with unclear dysphagia or esophagitis. Timely diagnosis and therapy might prevent potential sequelae such as esophageal stenosis or development of invasive squamous cell carcinoma. Further studies are needed to gain more knowledge about the pathogenesis and treatment options.
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Affiliation(s)
- Annegrit Decker
- Department of Medicine II, Gastroenterology, Hepatology, Endocrinology and Infectious Diseases, Medical Center-University of Freiburg, Faculty of Medicine, Freiburg 79106, Germany
| | - Franziska Schauer
- Department of Dermatology, Medical Center-University of Freiburg, Faculty of Medicine, Freiburg 79104, Germany
| | - Adhara Lazaro
- Department of Medicine, Institute of Exercise and Occupational Medicine, Medical Center–University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg 79106, Germany
| | - Carmen Monasterio
- Department of Medicine II, Gastroenterology, Hepatology, Endocrinology and Infectious Diseases, Medical Center-University of Freiburg, Faculty of Medicine, Freiburg 79106, Germany
| | - Arthur Robert Schmidt
- Department of Medicine II, Gastroenterology, Hepatology, Endocrinology and Infectious Diseases, Medical Center-University of Freiburg, Faculty of Medicine, Freiburg 79106, Germany
| | - Annette Schmitt-Graeff
- Institute for Dermatohistology, Pathology, and Molecular Pathology Prof. Dr. Laaf, Freiburg, Germany and: University of Freiburg, Freiburg 79106, Germany
| | - Wolfgang Kreisel
- Department of Medicine II, Gastroenterology, Hepatology, Endocrinology and Infectious Diseases, Medical Center-University of Freiburg, Faculty of Medicine, Freiburg 79106, Germany
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Varelas AI, Fürst S, Langner C. Mixed lymphocytic and collagenous inflammation of the entire gastrointestinal tract under therapy with serotonin and norepinephrine reuptake inhibitors. Virchows Arch 2022; 481:779-783. [PMID: 35655103 PMCID: PMC9636289 DOI: 10.1007/s00428-022-03351-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 04/27/2022] [Accepted: 05/23/2022] [Indexed: 01/01/2023]
Abstract
Drug-induced injury to the gastrointestinal tract has gained growing significance in recent years, and the list of causative medications keeps expanding. Herein, we present the case of a 45-year-old female with major depressive disorder treated with two serotonin and norepinephrine reuptake inhibitors (venlafaxine and duloxetine). She developed nausea and weight loss. Endoscopic evaluation of the upper and lower gastrointestinal tract rendered grossly normal mucosa in all segments. Histological examination, however, revealed lymphocytic esophagitis, collagenous gastritis, celiac disease-like intraepithelial lymphocytosis of the duodenum, and incomplete collagenous colitis. Gastrointestinal side effects of psychoactive drugs are largely underrecognized. This is the first report of a mixed lymphocytic and collagenous pattern of injury affecting esophagus, stomach, duodenum, and colon triggered by combined treatment with venlafaxine and duloxetine. In patients with unclear symptoms, obtaining biopsies from mucosa that is normal upon endoscopic inspection may render decisive clues for clinical management.
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Affiliation(s)
- Ana I Varelas
- Department of Pathology, Portuguese Institute of Oncology, Porto, Portugal
- Diagnostic and Research Institute of Pathology, Diagnostic and Research Centre for Molecular BioMedicine, Medical University of Graz, Neue Stiftingtalstraße 6, 8010, Graz, Austria
| | - Stefan Fürst
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Medical University of Graz, Graz, Austria
| | - Cord Langner
- Diagnostic and Research Institute of Pathology, Diagnostic and Research Centre for Molecular BioMedicine, Medical University of Graz, Neue Stiftingtalstraße 6, 8010, Graz, Austria.
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8
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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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9
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Saab-Chalhoub MW, Correa H, Anderson JL, Kovach AE, Salaria SN. Civatte Bodies in Pediatric Esophageal Biopsies: Does Lichen Esophagitis Pattern Occur in Children? Pediatr Dev Pathol 2022; 25:458-465. [PMID: 35452319 DOI: 10.1177/10935266221090081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE AND CONTEXT Civatte bodies (CB) are associated with cutaneous and mucosal lichen planus in adults. They are a distinct feature of Lichen Esophagitis Pattern, which is not well described in children. We characterized clinicopathologic associations of archival esophageal CB at our Children's Hospital to determine whether lichen planus or Lichen Esophagitis Pattern occurs in children. METHOD Pathology records were queried for pediatric esophageal biopsy diagnoses containing "CB," "apoptosis, "necrosis," or "dyskeratosis." Cases with concurrent eosinophilic/acute esophagitis were excluded. H&E slides and clinical reports were reviewed. KEY RESULTS Biopsies with CB or similar were identified from 19 patients and had been termed "dyskeratotic cells" in 8 reports. Patients had variable age and presenting symptoms, male predominance (74%), and frequent clinical history of polypharmacy (47%), Crohn disease (42%), and/or celiac disease (21%). Civatte bodies were prominent in the distal esophagus (95%), as few isolated cells (63%), and with variable chronic inflammation (absent, pauci-inflammatory, and lichen planus-like in approximately one-third of cases each). CONCLUSIONS We show that esophageal CB from pediatric patients are under-recognized and may have different features and implications compared to Lichen Esophagitis Pattern in adults. Recognition and documentation of pediatric esophageal CB is needed to understand their clinical significance.
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Affiliation(s)
- Mario W Saab-Chalhoub
- Division of Gastrointestinal Pathology, Department of Pathology, Microbiology & Immunology, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Hernán Correa
- Division of Pediatric Pathology, Department of Pathology, Microbiology & Immunology, Monroe Carell Jr. Children's Hospital at Vanderbilt, 21629Vanderbilt University Medical Center, Nashville, TN, USA
| | - Julia L Anderson
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Alexandra E Kovach
- Division of Pediatric Pathology, Department of Pathology, Microbiology & Immunology, Monroe Carell Jr. Children's Hospital at Vanderbilt, 21629Vanderbilt University Medical Center, Nashville, TN, USA
| | - Safia N Salaria
- Division of Gastrointestinal Pathology, Department of Pathology, Microbiology & Immunology, 12328Vanderbilt University Medical Center, Nashville, TN, USA
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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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11
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Kővári B, Pai RK. Upper Gastrointestinal Tract Involvement in Inflammatory Bowel Diseases: Histologic Clues and Pitfalls. Adv Anat Pathol 2022; 29:2-14. [PMID: 34310370 PMCID: PMC8663524 DOI: 10.1097/pap.0000000000000311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The upper gastrointestinal (UGI) manifestations of inflammatory bowel diseases (IBDs) are frequently obscured by classic ileal and colonic symptoms and are reported to involve only 0.5% to 4% of adult patients. However, because of the improvement of endoscopic techniques and the growing use of esophagogastroduodenososcopy with biopsy, both asymptomatic and clinically significant esophageal, gastric, and duodenal manifestations are increasingly recognized. The UGI involvement in IBD was historically synonymous with Crohn's disease (CD), but the doctrine of ulcerative colitis (UC) being limited to the colon has been challenged, and UC-related gastroduodenal lesions have been reported. The diagnosis of UGI IBD should ideally rely on a combination of the clinical history, endoscopic picture, and histologic features. Although endoscopic changes such as aphthoid or longitudinal ulcers and bamboo-joint-like pattern are suggestive of CD, histologic evaluation increases the sensitivity of the IBD diagnosis since histologic alterations may be present in endoscopically unremarkable mucosa. Conversely, in many cases, the histologic findings are nonspecific, and the knowledge of clinical history is vital for reaching an accurate diagnosis. The presence of epithelioid granuloma is highly suggestive of CD but is present in a minority of CD cases; thus, pathologists should be aware of how to diagnose UGI IBD in the absence of granulomata. This article reviews the most important clinical, endoscopic, and histologic features of IBD-associated esophagitis, gastritis, and duodenitis, as well as the IBD-related manifestations in the biliary tract and the postcolectomy setting.
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Affiliation(s)
- Bence Kővári
- Department of Pathology, Henry Lee Moffitt Cancer Center and Research Institute, Tampa, FL
- Department of Pathology, University of Szeged and Albert Szent-Györgyi Health Center, Szeged, Hungary
| | - Rish K. Pai
- Department of Laboratory Medicine and Pathology, Mayo Clinic Arizona, Scottsdale, AZ
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Salimian KJ, Birkness-Gartman J, Waters KM. The path(ology) from reflux oesophagitis to Barrett oesophagus to oesophageal adenocarcinoma. Pathology 2021; 54:147-156. [PMID: 34711413 DOI: 10.1016/j.pathol.2021.08.006] [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: 08/09/2021] [Revised: 08/23/2021] [Accepted: 08/23/2021] [Indexed: 02/07/2023]
Abstract
This review seeks to summarise the steps in the path from reflux oesophagitis to Barrett oesophagus to oesophageal adenocarcinoma. The epidemiology, clinical presentation, definitions, pathological features, diagnostic pitfalls, and emerging concepts are reviewed for each entity. The histological features of reflux oesophagitis can be variable and are not specific. Cases of reflux oesophagitis with numerous eosinophils are difficult to distinguish from eosinophilic oesophagitis and other oesophagitides with eosinophils (Crohn's disease, medication effect, and connective tissue disorders). In reflux oesophagitis, the findings are often most pronounced in the distal oesophagus, the eosinophils are randomly distributed throughout the epithelium, and eosinophilic abscesses and degranulated eosinophils are rare. For reflux oesophagitis with prominent lymphocytes, clinical history and ancillary clinical studies are paramount to distinguish reflux oesophagitis from other causes of lymphocytic oesophagitis pattern. For Barrett oesophagus, the definition remains a hotly debated topic for which the requirement for intestinal metaplasia to make the diagnosis is not applied unanimously across the globe. Assessing for dysplasia is a challenging aspect of the histological interpretation that guides clinical management. We describe the histological features that we find useful in making this evaluation. Oesophageal adenocarcinoma has been steadily increasing in incidence and has a poor prognosis. The extent of invasion can be overdiagnosed due to a duplicated muscularis mucosae. We also describe the technical factors that can lead to challenges in distinguishing the mucosal and deep margins of endoscopic resections. Lastly, we give an overview of targeted therapies with emerging importance and the ancillary tests that can identify the cases best suited for each therapy.
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Affiliation(s)
- Kevan J Salimian
- Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Kevin M Waters
- Department of Pathology and Laboratory Medicine, Cedars Sinai Medical Center, Los Angeles, CA, USA.
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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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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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15
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Zhang ML, Deshpande V. Histopathology of Gastrointestinal Immune-related Adverse Events: A Practical Review for the Practicing Pathologist. Am J Surg Pathol 2021; 46:e15-e26. [PMID: 33999556 DOI: 10.1097/pas.0000000000001730] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Immune checkpoint inhibitors target checkpoint proteins with the goal of reinvigorating the host immune system and thus restoring antitumor response. With the dramatic increase in the use of checkpoint inhibitors for cancer treatment, surgical pathologists have assumed a major role in predicting the therapeutic efficacy (score based on programmed cell death ligand 1 immunohistochemistry and mismatch repair protein loss) as well as diagnosing the complications associated with these medications. Immune-related adverse events (irAEs) manifest as histologic changes seen in both the upper and lower gastrointestinal tract, and when viewed in isolation, may be morphologically indistinguishable from a wide range of diseases including infections, celiac disease, and inflammatory bowel disease, among others. Evaluation of biopsies from both the upper and lower gastrointestinal tract can aid in the distinction of gastrointestinal irAEs from their mimics. In the liver, the histologic changes of hepatic irAEs overlap with de novo diseases associated with hepatitic and cholangitic patterns of injury. The diagnosis of irAEs requires communication and collaboration from the pathologist, oncologist, and gastroenterologist. This review provides a background framework and illustrates the histologic features and differential diagnosis of gastrointestinal and hepatic irAEs.
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Affiliation(s)
- M Lisa Zhang
- Department of Pathology, Massachusetts General Hospital Harvard Medical School, Boston, MA
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16
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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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17
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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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18
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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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