Difference between revisions of "Eosinophilic esophagitis"

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#redirect [[Esophagus#Eosinophilic_esophagitis]]
'''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.<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 | url = http://www.archivesofpathology.org/doi/full/10.1043/1543-2165-134.6.815 }}</ref>
 
Clinical:
*Dysphagia<ref>URL: [http://www.medicinenet.com/eosinophilic_esophagitis/page2.htm#tocc http://www.medicinenet.com/eosinophilic_esophagitis/page2.htm#tocc]. Accessed on: 1 December 2009.</ref> - classic presentation.
*Dyspepsia.
**Often mimics [[gastroesophageal reflux disease]] (GERD).<ref name=pmid19596009>{{Cite journal  | last1 = Rothenberg | first1 = ME. | title = Biology and treatment of eosinophilic esophagitis. | journal = Gastroenterology | volume = 137 | issue = 4 | pages = 1238-49 | month = Oct | year = 2009 | doi = 10.1053/j.gastro.2009.07.007 | PMID = 19596009 }}</ref>
 
Treatment:
*Avoid exacerbating antigens.
*Topical corticosteroids, e.g. fluticasone.
*Do not respond to proton pump inhibitors.
 
Biopsies:
*Should be taken from: upper, mid, lower and submitted in separate containers (eosinophilia present through-out-- to differentiate from GERD).
 
Associations:
*Atopy.<ref name=Ref_GLP19>{{Ref GLP|19}}</ref>
*[[Celiac disease]].<ref name=pmid19841598>{{cite journal |author=Leslie C, Mews C, Charles A, Ravikumara M |title=Celiac disease and eosinophilic esophagitis: a true association |journal=J. Pediatr. Gastroenterol. Nutr. |volume=50 |issue=4 |pages=397–9 |year=2010 |month=April |pmid=19841598 |doi=10.1097/MPG.0b013e3181a70af4 |url=}}</ref>
*Oral antigens, i.e. particular foods.<ref name=pmid19596009/>
*Familial association.<ref name=pmid19596009/>
*Young ~ 35 years old.<ref name=pmid23382628/>
*Male > female (3:1).<ref name=pmid23382628>{{Cite journal  | last1 = Dellon | first1 = ES. | last2 = Erichsen | first2 = R. | last3 = Pedersen | first3 = L. | last4 = Shaheen | first4 = NJ. | last5 = Baron | first5 = JA. | last6 = Sørensen | first6 = HT. | last7 = Vyberg | first7 = M. | title = Development and validation of a registry-based definition of eosinophilic esophagitis in Denmark. | journal = World J Gastroenterol | volume = 19 | issue = 4 | pages = 503-10 | month = Jan | year = 2013 | doi = 10.3748/wjg.v19.i4.503 | PMID = 23382628 }}</ref>
 
==Gross/endoscopic==
*'''Trachealization'''; eosphagus looks like trachea.<ref name=pmid19636182>{{Cite journal  | last1 = Al-Hussaini | first1 = AA. | last2 = Semaan | first2 = T. | last3 = El Hag | first3 = IA. | title = Esophageal trachealization: a feature of eosinophilic esophagitis. | journal = Saudi J Gastroenterol | volume = 15 | issue = 3 | pages = 193-5 | month =  | year =  | doi = 10.4103/1319-3767.54747 | PMID = 19636182 }}
</ref>
**[[AKA]] ''feline esophagus''.<ref>URL: [http://www.ajronline.org/cgi/reprint/164/4/900.pdf  http://www.ajronline.org/cgi/reprint/164/4/900.pdf]. Accessed on: 4 October 2010.</ref>
*White.
 
DDx (endoscopic):
*[[Candida esophagitis]]
 
===Image===
<gallery>
Image:Multi_ring_esophagus.jpg | Trachealization of the esophagus. (WC)
</gallery>
*[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2841420/figure/F0001/ Trachealization - radiograph (nih.gov)].
 
==Microscopic==
Features:<ref name=Ref_GLP19>{{Ref GLP|19}}</ref>
*Mucosa with "abundant eosinophils".
*[[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.<ref name=Ref_PBoD804>{{Ref PBoD|804}}</ref>
 
Notes "abundant eosinophils":
*Criteria for number of eosinophils/area is '''''highly variable'''''; there is a 23X fold variation in published values and only 11% of studies actually define an area (most studies, embarassing for pathologists that understand this issue, only give the number of eosinophils per "HPF")!<ref name=pmid17617209>{{cite journal |author=Dellon ES, Aderoju A, Woosley JT, Sandler RS, Shaheen NJ |title=Variability in diagnostic criteria for eosinophilic esophagitis: a systematic review |journal=Am. J. Gastroenterol. |volume=102 |issue=10 |pages=2300–13 |year=2007 |month=October |pmid=17617209 |doi=10.1111/j.1572-0241.2007.01396.x |url=}}</ref>
**Interrater variability is low, i.e. good, if the procedure is standardized.<ref name=pmid19830560>{{Cite journal  | last1 = Dellon | first1 = ES. | last2 = Fritchie | first2 = KJ. | last3 = Rubinas | first3 = TC. | last4 = Woosley | first4 = JT. | last5 = Shaheen | first5 = NJ. | title = Inter- and intraobserver reliability and validation of a new method for determination of eosinophil counts in patients with esophageal eosinophilia. | journal = Dig Dis Sci | volume = 55 | issue = 7 | pages = 1940-9 | month = Jul | year = 2010 | doi = 10.1007/s10620-009-1005-z | PMID = 19830560 }}</ref>
*The most commonly reported cut points are 15, 20 and 24 eosinophils/HPF, without defining HPF.<ref name=pmid17617209/>
**The ''Foundation Series'' book<ref name=Ref_GLP19>{{Ref GLP|19}}</ref> says: "> 20/HPF"; ''[[onlinepathology]]'' sees this definition as garbage, as "HPF" is not defined (see [[HPFitis]]).
**There is a consensus paper<ref name=pmid17919504>{{cite journal |author=Furuta GT, Liacouras CA, Collins MH, ''et al.'' |title=Eosinophilic esophagitis in children and adults: a systematic review and consensus recommendations for diagnosis and treatment |journal=Gastroenterology |volume=133 |issue=4 |pages=1342–63 |year=2007 |month=October |pmid=17919504 |doi=10.1053/j.gastro.2007.08.017 |url=}}</ref> that makes note of [[HPFitis]]... and then goes on to ignore to whole issue by defining EE as 15/HPF.  It blows my mind that the people could be so will fully blind and that the idiotic reviewers didn't understand this.
**Most resident microscopes at the Toronto teaching hospitals have 22 mm eye pieces and have for their highest magnification objective a 40X.  De facto, this means most people in Toronto are using the Liacouras ''et al.'' definition.<ref name=pmid16361045>{{cite journal |author=Liacouras CA, Spergel JM, Ruchelli E, ''et al.'' |title=Eosinophilic esophagitis: a 10-year experience in 381 children |journal=Clin. Gastroenterol. Hepatol. |volume=3 |issue=12 |pages=1198–206 |year=2005 |month=December |pmid=16361045 |doi= |url=}}</ref>
*Eosinophils may be patchy.<ref name=pmid22502795>{{Cite journal  | last1 = Saffari | first1 = H. | last2 = Peterson | first2 = KA. | last3 = Fang | first3 = JC. | last4 = Teman | first4 = C. | last5 = Gleich | first5 = GJ. | last6 = Pease | first6 = LF. | title = Patchy eosinophil distributions in an esophagectomy specimen from a patient with eosinophilic esophagitis: Implications for endoscopic biopsy. | journal = J Allergy Clin Immunol | volume = 130 | issue = 3 | pages = 798-800 | month = Sep | year = 2012 | doi = 10.1016/j.jaci.2012.03.009 | PMID = 22502795 }}</ref>
 
DDx:<ref name=Ref_Odze244>{{Ref Odze|244}}</ref>
*[[Gastroesophageal reflux disease]] - no mid and proximal involvement.
*[[Infectious esophagitis]].
*Eosinophilic gastroenteritis.
*Hypereosinophilic syndrome.
 
===Images===
<gallery>
Image:Eosinophilic_esophagitis_-_2_-_very_high_mag.jpg | Eosinophilic esophagitis - very high mag. (WC)
Image:Eosinophilic_esophagitis_-_2_-_high_mag.jpg | Eosinophilic esophagitis - high mag. (WC)
</gallery>
*[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2841420/figure/F0003/ Eosinophilic esophagitis (nih.gov)].
*[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/>
 
==Sign out==
<pre>
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).
 
Literature valves show a large variation when defining eosinophilic esophagitis
and frequently use "HPF" as a measure of area, which is not a standardized measure.
[Am. J. Gastroenterol. 102 (10): 2300–13.]
 
Common cut-points are 15 eosinophils/HPF and 20 eosinophils/HPF, where HPF is
often undefined.
 
The above findings are suggestive of eosinophilic esophagitis in the proper
clinical context.
</pre>
 
===Patchy eosinophils===
<pre>
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.
 
Literature valves show a large variation when defining eosinophilic esophagitis
and frequently use "HPF" as a measure of area, which is not a standardized measure.
[Am. J. Gastroenterol. 102 (10): 2300 13.]
 
Common cut-points are 15 eosinophils/HPF and 20 eosinophils/HPF, where HPF is
often undefined.
</pre>
 
===Histology suggestive===
<pre>
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.
</pre>
 
==See also==
*[[Esophagus]].
*[[Eosinophilic colitis]].
*[[Eosinophil]].
 
==References==
{{Reflist|2}}


[[Category:Diagnosis]]
[[Category:Diagnosis]]
[[Category:Esophagus]]
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