Difference between revisions of "Gastroesophageal reflux disease"

Revision as of 18:23, 31 January 2014

Gastroesophageal reflux disease, abbreviated GERD, is a common pathology of the esophagus. It is also known as reflux esophagitis.

It is occasionally abbreviated GORD (gastro-oesophageal reflux disease).

General

Clinical:

Usually chest pain
+/-Abdominal pain.
+/-Vomiting.
+/-Blood loss.

Treatment:

Treated with proton pump inhibitors (PPIs).

DDx (clinical):

Eosinophilic esophagitis.

Gross

Erythema.
Erosions.
+/-Ulceration.

Note:

Many be graded using Savary-Miller classification.

Images:

Savary-Miller classification - endoscopic images (gastrohep.com).

Microscopic

Features:

Basal cell hyperplasia;^[1] > 3 cells thick or >15% of epithelial thickness.
Papillae elongated; papillae reach into the top 1/3 of the epithelial layer.^[2]
Inflammation, esp. eosinophils, lymphocytes with convoluted nuclei ("squiggle cells").
+/-Intraepithelial edema.
+/-Apoptotic cells.^[3]

Notes:

Intraepithelial cells with irregular nuclear contours, "squiggle cells" (T lymphocytes^[4]), may mimic neutrophils.
Changes may be focal.
PPI effect may be seen in a concurrent gastric biopsy.

DDx:

Eosinophilic esophagitis - characterized by similar histomorphologic features. The key difference is: more eosinophils.
Barrett's esophagus - intestinal metaplasia may be minimal.

Images:

EE versus GERD (archivesofpathology.org).^[5]

Sign out

Poorly oriented

ESOPHAGUS, BIOPSY:
- SQUAMOUS MUCOSA WITH BASAL CELL HYPERPLASIA, INTRAEPITHELIAL EDEMA AND RARE INTRAEPITHELIAL 
EOSINOPHILS -- COMPATIBLE WITH GASTROESOPHAGEAL REFLUX.

Columnar epithelium present

ESOPHAGUS, BIOPSY:
- SQUAMOUS MUCOSA WITH BASAL CELL HYPERPLASIA, INTRAEPITHELIAL EDEMA AND RARE INTRAEPITHELIAL 
EOSINOPHILS -- COMPATIBLE WITH GASTROESOPHAGEAL REFLUX.
- COLUMNAR EPITHELIUM WITH MODERATE CHRONIC INACTIVE INFLAMMATION.
- NEGATIVE FOR INTESTINAL METAPLASIA.
- NEGATIVE FOR DYSPLASIA AND NEGATIVE FOR MALIGNANCY.

Ulceration present

ESOPHAGUS, DISTAL, BIOPSY:
- SQUAMOUS MUCOSA WITH BASAL CELL HYPERPLASIA, INTRAEPITHELIAL EDEMA, RARE
  INTRAEPITHELIAL EOSINOPHILS AND EVIDENCE OF ULCERATION -- COMPATIBLE WITH
  GASTROESOPHAGEAL REFLUX.
- COLUMNAR EPITHELIUM WITH MODERATE CHRONIC INACTIVE INFLAMMATION.
- NEGATIVE FOR INTESTINAL METAPLASIA.
- NEGATIVE FOR DYSPLASIA AND NEGATIVE FOR MALIGNANCY.

COMMENT:
PAS-D staining is negative for microorganisms.

BE and GERD present

ESOPHAGUS (DISTAL), BIOPSY:
- COLUMNAR EPITHELIUM WITH INTESTINAL METAPLASIA AND MODERATE CHRONIC INFLAMMATION,
  SEE COMMENT.
- SQUAMOUS MUCOSA WITH BASAL CELL HYPERPLASIA, INTRAEPITHELIAL EDEMA AND RARE
  INTRAEPITHELIAL EOSINOPHILS -- COMPATIBLE WITH GASTROESOPHAGEAL REFLUX.
- NEGATIVE FOR DYSPLASIA AND NEGATIVE FOR MALIGNANCY.

COMMENT:
The findings are consistent with Barrett's esophagus in the appropriate endoscopic setting.

References

↑ Steiner, SJ.; Kernek, KM.; Fitzgerald, JF. (May 2006). "Severity of basal cell hyperplasia differs in reflux versus eosinophilic esophagitis.". J Pediatr Gastroenterol Nutr 42 (5): 506-9. doi:10.1097/01.mpg.0000221906.06899.1b. PMID 16707971.
↑ Cotran, Ramzi S.; Kumar, Vinay; Fausto, Nelson; Nelso Fausto; Robbins, Stanley L.; Abbas, Abul K. (2005). Robbins and Cotran pathologic basis of disease (7th ed.). St. Louis, Mo: Elsevier Saunders. pp. 804. ISBN 0-7216-0187-1.
↑ Wetscher GJ, Schwelberger H, Unger A, et al. (December 1998). "Reflux-induced apoptosis of the esophageal mucosa is inhibited in Barrett's epithelium". Am. J. Surg. 176 (6): 569–73. PMID 9926792.
↑ Cucchiara, S.; D'Armiento, F.; Alfieri, E.; Insabato, L.; Minella, R.; De Magistris, TM.; Scoppa, A. (Nov 1995). "Intraepithelial cells with irregular nuclear contours as a marker of esophagitis in children with gastroesophageal reflux disease.". Dig Dis Sci 40 (11): 2305-11. PMID 7587806.
↑ Genevay, M.; Rubbia-Brandt, L.; Rougemont, AL. (Jun 2010). "Do eosinophil numbers differentiate eosinophilic esophagitis from gastroesophageal reflux disease?". Arch Pathol Lab Med 134 (6): 815-25. doi:10.1043/1543-2165-134.6.815. PMID 20524860.

[pmid16707971-1] Steiner, SJ.; Kernek, KM.; Fitzgerald, JF. (May 2006). "Severity of basal cell hyperplasia differs in reflux versus eosinophilic esophagitis.". J Pediatr Gastroenterol Nutr 42 (5): 506-9. doi:10.1097/01.mpg.0000221906.06899.1b. PMID 16707971.

[Ref_PBoD804-2] Cotran, Ramzi S.; Kumar, Vinay; Fausto, Nelson; Nelso Fausto; Robbins, Stanley L.; Abbas, Abul K. (2005). Robbins and Cotran pathologic basis of disease (7th ed.). St. Louis, Mo: Elsevier Saunders. pp. 804. ISBN 0-7216-0187-1.

[pmid9926792-3] Wetscher GJ, Schwelberger H, Unger A, et al. (December 1998). "Reflux-induced apoptosis of the esophageal mucosa is inhibited in Barrett's epithelium". Am. J. Surg. 176 (6): 569–73. PMID 9926792.

[pmid7587806-4] Cucchiara, S.; D'Armiento, F.; Alfieri, E.; Insabato, L.; Minella, R.; De Magistris, TM.; Scoppa, A. (Nov 1995). "Intraepithelial cells with irregular nuclear contours as a marker of esophagitis in children with gastroesophageal reflux disease.". Dig Dis Sci 40 (11): 2305-11. PMID 7587806.

[pmid20524860-5] Genevay, M.; Rubbia-Brandt, L.; Rougemont, AL. (Jun 2010). "Do eosinophil numbers differentiate eosinophilic esophagitis from gastroesophageal reflux disease?". Arch Pathol Lab Med 134 (6): 815-25. doi:10.1043/1543-2165-134.6.815. PMID 20524860.

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[2]

[3]

[4]

[5]

@@ Line 1: / Line 1: @@
-#redirect [[Esophagus#Gastroesophageal_reflux_disease]]
+'''Gastroesophageal reflux disease''', abbreviated '''GERD''', is a common pathology of the [[esophagus]].  It is also known as '''reflux esophagitis'''.
+It is occasionally abbreviated  ''GORD'' (gastro-oesophageal reflux disease).
+==General==
+Clinical:
+*Usually chest pain
+*+/-Abdominal pain.
+*+/-Vomiting.
+*+/-Blood loss.
+Treatment:
+*Treated with [[proton pump inhibitor]]s (PPIs).
+DDx (clinical):
+*[[Eosinophilic esophagitis]].
+==Gross==
+*Erythema.
+*Erosions.
+*+/-Ulceration.
+Note:
+*Many be graded using ''Savary-Miller classification''.
+Images:
+*[http://www.gastrohep.com/images/image.asp?id=171 Savary-Miller classification - endoscopic images (gastrohep.com)].
+==Microscopic==
+Features:
+#[[Basal cell hyperplasia]];<ref name=pmid16707971>{{Cite journal  | last1 = Steiner | first1 = SJ. | last2 = Kernek | first2 = KM. | last3 = Fitzgerald | first3 = JF. | title = Severity of basal cell hyperplasia differs in reflux versus eosinophilic esophagitis. | journal = J Pediatr Gastroenterol Nutr | volume = 42 | issue = 5 | pages = 506-9 | month = May | year = 2006 | doi = 10.1097/01.mpg.0000221906.06899.1b | PMID = 16707971 }}</ref> > 3 cells thick ''or'' >15% of epithelial thickness.
+#Papillae elongated; papillae reach into the top 1/3 of the epithelial layer.<ref name=Ref_PBoD804>{{Ref PBoD|804}}</ref>
+#Inflammation, esp. eosinophils, lymphocytes with convoluted nuclei ("squiggle cells").
+#+/-Intraepithelial edema.
+#+/-Apoptotic cells.<ref name=pmid9926792>{{cite journal |author=Wetscher GJ, Schwelberger H, Unger A, ''et al.'' |title=Reflux-induced apoptosis of the esophageal mucosa is inhibited in Barrett's epithelium |journal=Am. J. Surg. |volume=176 |issue=6 |pages=569–73 |year=1998 |month=December |pmid=9926792 |doi= |url=}}</ref>
+Notes:
+*Intraepithelial cells with irregular nuclear contours, "squiggle cells" (T lymphocytes<ref name=pmid7587806>{{Cite journal  | last1 = Cucchiara | first1 = S. | last2 = D'Armiento | first2 = F. | last3 = Alfieri | first3 = E. | last4 = Insabato | first4 = L. | last5 = Minella | first5 = R. | last6 = De Magistris | first6 = TM. | last7 = Scoppa | first7 = A. | title = Intraepithelial cells with irregular nuclear contours as a marker of esophagitis in children with gastroesophageal reflux disease. | journal = Dig Dis Sci | volume = 40 | issue = 11 | pages = 2305-11 | month = Nov | year = 1995 | doi =  | PMID = 7587806 }}</ref>), may mimic [[neutrophil]]s.
+*Changes may be focal.
+*[[PPI effect]] may be seen in a concurrent [[stomach|gastric]] biopsy.
+DDx:
+*[[Eosinophilic esophagitis]] - characterized by similar histomorphologic features. The key difference is: more [[eosinophil]]s.
+*[[Barrett's esophagus]] - intestinal metaplasia may be minimal.
+Images:
+*[http://www.archivesofpathology.org/action/showFullPopup?id=i1543-2165-134-6-815-f03&doi=10.1043%2F1543-2165-134.6.815 EE versus GERD (archivesofpathology.org)].<ref name=pmid20524860>{{Cite journal  | last1 = Genevay | first1 = M. | last2 = Rubbia-Brandt | first2 = L. | last3 = Rougemont | first3 = AL. | title = Do eosinophil numbers differentiate eosinophilic esophagitis from gastroesophageal reflux disease? | journal = Arch Pathol Lab Med | volume = 134 | issue = 6 | pages = 815-25 | month = Jun | year = 2010 | doi = 10.1043/1543-2165-134.6.815 | PMID = 20524860 }}</ref>
+==Sign out==
+===Poorly oriented===
+<pre>
+ESOPHAGUS, BIOPSY:
+- SQUAMOUS MUCOSA WITH BASAL CELL HYPERPLASIA, INTRAEPITHELIAL EDEMA AND RARE INTRAEPITHELIAL
+EOSINOPHILS -- COMPATIBLE WITH GASTROESOPHAGEAL REFLUX.
+</pre>
+===Columnar epithelium present===
+<pre>
+ESOPHAGUS, BIOPSY:
+- SQUAMOUS MUCOSA WITH BASAL CELL HYPERPLASIA, INTRAEPITHELIAL EDEMA AND RARE INTRAEPITHELIAL
+EOSINOPHILS -- COMPATIBLE WITH GASTROESOPHAGEAL REFLUX.
+- COLUMNAR EPITHELIUM WITH MODERATE CHRONIC INACTIVE INFLAMMATION.
+- NEGATIVE FOR INTESTINAL METAPLASIA.
+- NEGATIVE FOR DYSPLASIA AND NEGATIVE FOR MALIGNANCY.
+</pre>
+===Ulceration present===
+<pre>
+ESOPHAGUS, DISTAL, BIOPSY:
+- SQUAMOUS MUCOSA WITH BASAL CELL HYPERPLASIA, INTRAEPITHELIAL EDEMA, RARE
+  INTRAEPITHELIAL EOSINOPHILS AND EVIDENCE OF ULCERATION -- COMPATIBLE WITH
+  GASTROESOPHAGEAL REFLUX.
+- COLUMNAR EPITHELIUM WITH MODERATE CHRONIC INACTIVE INFLAMMATION.
+- NEGATIVE FOR INTESTINAL METAPLASIA.
+- NEGATIVE FOR DYSPLASIA AND NEGATIVE FOR MALIGNANCY.
+COMMENT:
+PAS-D staining is negative for microorganisms.
+</pre>
+===BE and GERD present===
+<pre>
+ESOPHAGUS (DISTAL), BIOPSY:
+- COLUMNAR EPITHELIUM WITH INTESTINAL METAPLASIA AND MODERATE CHRONIC INFLAMMATION,
+  SEE COMMENT.
+- SQUAMOUS MUCOSA WITH BASAL CELL HYPERPLASIA, INTRAEPITHELIAL EDEMA AND RARE
+  INTRAEPITHELIAL EOSINOPHILS -- COMPATIBLE WITH GASTROESOPHAGEAL REFLUX.
+- NEGATIVE FOR DYSPLASIA AND NEGATIVE FOR MALIGNANCY.
+COMMENT:
+The findings are consistent with Barrett's esophagus in the appropriate endoscopic setting.
+</pre>
+==See also==
+*[[Esophagus]].
+*[[Barrett's esophagus]].
+*[[PPI effect]].
+==References==
+{{Reflist|2}}
+[[Category:Esophagus]]
 [[Category:Diagnosis]]