Eosinophilic esophagitis

Eosinophilic esophagitis
Diagnosis in short
Eosinophilic esophagitis. H&E stain.
LM	mucosa with abundant eosinophils (60 per mm*mm), basal cell hyperplasia (three cells thick or >15% of epithelial thickness), papillae elongated (reach into the top 1/3 of the epithelial layer)
LM DDx	GERD
Site	esophagus
Associated Dx	atopy, celiac disease
Clinical history	may be unresponsive to proton pump inhibitors (PPIs)
Symptoms	similar to GERD
Prevalence	uncommon
Endoscopy	trachealization of esophagus (AKA feline esophagus)
Clin. DDx	GERD

Eosinophilic esophagitis, abbreviated EE, is relatively uncommon pathology of the esophagus with some similarities to gastroesophageal reflux disease (GERD).

General

• The current thinking is that it is a clinico-pathologic diagnosis.

Clinical:

• Dysphagia - classic presentation.
• Dyspepsia.
  • Often mimics gastroesophageal reflux disease (GERD).

Treatment:

• Avoid exacerbating antigens.
• Topical corticosteroids, e.g. fluticasone.

Note on treatment:

• The classic teaching was that EE does not respond to proton pump inhibitors; thinking on this has evolved.

Biopsies:

• Should be taken from: upper, mid, lower and submitted in separate containers (eosinophilia present through-out-- to differentiate from GERD).

Associations:

• Atopy.
• Celiac disease.
• Oral antigens, i.e. particular foods.
• Familial association.
• Young ~ 35 years old.
• Male > female (3:1).

Gross/endoscopic

• Trachealization; esophagus looks like trachea.
  • AKA feline esophagus.
• White.

DDx (endoscopic):

• Candida esophagitis

Image

• 

  Trachealization of the esophagus. (WC)

• Trachealization - radiograph (nih.gov).

Microscopic

Features:

• Mucosa with abundant eosinophils - the consensus on eosinophils per area is 60/mm*mm.
• Basal cell hyperplasia.
  • Three cells thick or >15% of epithelial thickness.
• Papillae elongated.
  • Papillae that reach into the top 1/3 of the epithelial layer - definition for GERD.

Note:

• Many microscopes have an eye piece diameter of 22 mm. Thus, the field area (for a "HPF") with the 40x objective is ~0.2376 mm*mm. This works out to approximately 15 eosinophils/HPF.

DDx:

• Gastroesophageal reflux disease - no mid and proximal involvement.
• Infectious esophagitis.
• Eosinophilic gastroenteritis.
• Hypereosinophilic syndrome.

Images

• 

  Intermed. mag. (WC)

• 

  High mag. (WC)

• 

  Very high mag. (WC)

• 

  High mag. (WC)

• 

  Very high mag. (WC)

www

• Eosinophilic esophagitis (nih.gov).
• EE versus GERD (archivesofpathology.org).
• Eosinophilic esophagitis - nice pictures (medunigraz.at).

Sign out

A. Distal Esophagus, Biopsy:
       - Squamous mucosa with basal cell hyperplasia, abundant intraepithelial
         eosinophils, edema, and papillary elongation, see comment.
       - NEGATIVE for columnar type epithelium.
       - NEGATIVE for dysplasia.

B. Mid Esophagus, Biopsy:
       - Squamous mucosa with basal cell hyperplasia, abundant intraepithelial
         eosinophils, edema, and papillary elongation, see comment.
       - NEGATIVE for dysplasia.

COMMENT:
There are approximately 35 eosinophils per 0.2376 mm*mm (1 HPF) in
both Part A and Part B.

The above findings are suggestive of eosinophilic esophagitis in the proper
clinical context.

Block letters

ESOPHAGUS, DISTAL, BIOPSY:
- SQUAMOUS MUCOSA WITH BASAL CELL HYPERPLASIA, ABUNDANT INTRAEPITHELIAL EOSINOPHILS, 
  EDEMA, AND PAPILLARY ELONGATION, SEE COMMENT.
- STAINS (PAS-D, GMS) NEGATIVE FOR MICROORGANISMS.
- NEGATIVE FOR INTESTINAL METAPLASIA.
- NEGATIVE FOR DYSPLASIA.

COMMENT:
There are approximately 65 eosinophils per 0.2376 mm*mm (1 HPF). 

The above findings are suggestive of eosinophilic esophagitis in the proper
clinical context.

Patchy eosinophils

ESOPHAGUS (DISTAL), BIOPSY:
- SQUAMOUS MUCOSA WITH BASAL CELL HYPERPLASIA, INTRAEPITHELIAL EDEMA AND ONLY
  FOCALLY ABUNDANT INTRAEPITHELIAL EOSINOPHILS, SEE COMMENT.
- COLUMNAR EPITHELIUM WITH MODERATE CHRONIC INFLAMMATION, AND PANCREATIC
  ACINAR METAPLASIA.
- NEGATIVE FOR INTESTINAL METAPLASIA.
- NEGATIVE FOR DYSPLASIA AND NEGATIVE FOR MALIGNANCY.

COMMENT:
One high power field (field diameter 0.55 mm) has 25 eosinophils. The findings are
compatible with gastroesophageal reflux; however, eosinophilic esophagitis is also a
consideration. Clinical correlation is required.

Histology suggestive

ESOPHAGUS, BIOPSY:
- SQUAMOUS MUCOSA WITH MARKED BASAL CELL HYPERPLASIA, FOCALLY ABUNDANT
  INTRAEPITHELIAL EOSINOPHILS, EDEMA, AND PAPILLARY ELONGATION, SEE COMMENT.
- NEGATIVE FOR INTESTINAL METAPLASIA.
- NEGATIVE FOR DYSPLASIA.

COMMENT:
Focally, there are approximately 35 eosinophils per 0.2376 mm*mm (1 HPF).

The above findings raise the possibility of eosinophilic esophagitis; clinical
correlation is suggested. A re-biopsy including a portion of the proximal esophagus
could be considered.

See also

• Esophagus.
• Eosinophilic colitis.
• Eosinophilic gastritis.