Gastroesophageal reflux disease

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Gastroesophageal reflux disease
Diagnosis in short

Micrograph showing histology compatible with gastroesophageal reflux disease. H&E stain.

LM basal cell hyperplasia (> 3 cells thick or >15% of epithelial thickness), papillae elongated (papillae reach into the top 1/3 of the epithelial layer), inflammation, esp. eosinophils, lymphocytes with convoluted nuclei ("squiggle cells"), +/-intraepithelial edema, +/-apoptotic cells, +/-glycogenation
LM DDx intestinal metaplasia (Barrett's esophagus), eosinophilic esophagitis, acute esophagitis
Site esophagus

Associated Dx obesity, Barrett's esophagus
Prevalence common
Endoscopy erythema, erosions, +/-ulceration.
Prognosis benign
Clin. DDx eosinophilic esophagitis, acute esophagitis
Treatment proton pump inhibitors

Gastroesophageal reflux disease, abbreviated GERD, is a common pathology of the esophagus. It is occasionally abbreviated GORD (gastro-oesophageal reflux disease).

Reflux esophagitis redirects here. It technically isn't a synonym.[1][2]

General

Clinical:

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

Treatment:

DDx (clinical):

Gross

  • Erythema.
  • Erosions.
  • +/-Ulceration.

Note:

  • Many be graded using Savary-Miller classification or Los Angeles classification.[3]

Images:

Los Angeles classification for GERD

Features:[4]

Classification Description
A mucosal break <=5 mm, not beyond the tops of two (adjacent) mucosal folds
B mucosal break >5 mm, not beyond the tops of two (adjacent) mucosal folds
C mucosa break beyond the tops of two mucosal folds but <75% of the esophageal circumference
D mucosal break >=75% of the esophageal circumference

Note:

  • Correlation with histology is poor; mucosal breaks are seen rarely.[3]

Microscopic

Features:

  1. Basal cell hyperplasia;[5] > 3 cells thick or >15% of epithelial thickness.
  2. Papillae elongated; papillae reach into the top 1/3 of the epithelial layer.[6]
  3. Inflammation, esp. eosinophils, lymphocytes with convoluted nuclei ("squiggle cells").
  4. +/-Intraepithelial edema.
  5. +/-Apoptotic cells.[7]
  6. +/-Glycogen - cytoplasm cleared (white).[8]

Notes:

  • Intraepithelial cells with irregular nuclear contours, "squiggle cells" (T lymphocytes[9]), may mimic neutrophils.
  • Changes may be focal.
  • PPI effect may be seen in a concurrent gastric biopsy.
  • Perinuclear clearing may be seen.[10]

DDx:

Images

www:

Stains

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.

See also

References

  1. Orbelo, DM.; Enders, FT.; Romero, Y.; Francis, DL.; Achem, SR.; Dabade, TS.; Crowell, MD.; Geno, DM. et al. (Jan 2014). "Once-Daily Omeprazole/Sodium Bicarbonate Heals Severe Refractory Reflux Esophagitis with Morning or Nighttime Dosing.". Dig Dis Sci. doi:10.1007/s10620-013-3017-y. PMID 24448652.
  2. Karbasi, A.; Ardestani, ME.; Ghanei, M.; Harandi, AA. (Jun 2013). "The association between reflux esophagitis and airway hyper-reactivity in patients with gastro-esophageal reflux.". J Res Med Sci 18 (6): 473-6. PMID 24250694.
  3. 3.0 3.1 Genta, RM.; Spechler, SJ.; Kielhorn, AF. (Jan 2011). "The Los Angeles and Savary-Miller systems for grading esophagitis: utilization and correlation with histology.". Dis Esophagus 24 (1): 10-7. doi:10.1111/j.1442-2050.2010.01092.x. PMID 20659145.
  4. URL: http://www.sciencedirect.com/science/article/pii/S2212097113700463. Accessed on: 14 April 2015
  5. 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.
  6. 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.
  7. 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.
  8. Vadva MD, Triadafilopoulos G (July 1993). "Glycogenic acanthosis of the esophagus and gastroesophageal reflux". J. Clin. Gastroenterol. 17 (1): 79–83. PMID 8409304.
  9. 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.
  10. URL: http://155.37.5.42/eAtlas/GI/1262.htm. Accessed on: 31 January 2014.
  11. 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.
  12. Hopkins, PM.; Kermeen, F.; Duhig, E.; Fletcher, L.; Gradwell, J.; Whitfield, L.; Godinez, C.; Musk, M. et al. (Aug 2010). "Oil red O stain of alveolar macrophages is an effective screening test for gastroesophageal reflux disease in lung transplant recipients.". J Heart Lung Transplant 29 (8): 859-64. doi:10.1016/j.healun.2010.03.015. PMID 20466562.