Ondrej Daum

Biopticka laborator & Sikl´s Institute of Pathology

Plzen, Czech Republic

(not related to GERD and systemic diseases)

(to say nothing of the GERD and the systemics)

Infectious esophagitis Viral (HSV, VZV, CMV, HIV)

Fungal (Candida, Aspergillus, Histoplasma, Cryptococcus, Blastomyces, Mucor, Coccidioides)

Bacterial (including Mycobacteria and Actinomyces)

Parasitic (Toxoplasma)

Eosinophilic esophagitis

Corrosive esophagitis

Radiation esophagitis

Toxic and drug/pill-associated esophagitis

LOW POWER• recognition / confirmation of

inflammatory nature

MEDIUM to HIGH

POWER• distribution and composition

of inflammatory infiltrate

• epithelial injury

• causative agent

Dg.

Personal

history

SerologyVirologyImmuno-

logy

Gross

Endo

Finding

Blood

count

Lymphocytic

Purulent

Eosinophilic

Granulomas

Sparse

GERD

Infectious

Crohn

GERD

Infectious

Drug/pill-associated

GERD

Eosinophilic esophagitis

Infectious

Crohn

Sarcoidosis

Mycobacterial

Corrosive

GVHD, Radiation

Toxic and drug-associated

Others

+ Eos & Neus

+ CLE

+ Eos & Neus

+ keratosis

+ mykoorganisms

focal distribution

+ granulomas

Lichenoid

interface changes

GERD

Candida

Crohn

Lichen planus

Lymphocytic

esophagitis

Lymphocytic esophagitis

? Definition:

> 20 (or 30 or 50) IELs/HPF

Peripapillary accentuation of IELs

Absent or rare Neus/Eos

Spongiosis

Absence of a known primary condition

Pattern associations:

Crohn diseases (pediatric biopsies!)

GERD (adults)

Allergic / Autoimmune / Immune deficiency (incl. HIV)

GSE

Achalasia

Infections

Personal history & Endoscopy:

Dysphagia, heartburn, bellyaches

Normal to BE

Hiatal hernia

Rings and furrows

Male, 12 years of age, esophageal ulcers

+ Eos & Lys

+ CLEGERD

+ keratosis

+ mykoorganisms

(+ Eos)

Candida

+ viral inclusions Viral esophagitis

+ pills in the ulcer

+ midesophagusPill esophagitis

History, serology,

immunology, IHC, virology

“Real” disease

Bystander

Candida in the esophagus

Clinical history:

Debilitated, immunocompromised (or not)

Dysphagia, odynophagia

“globus sensation”

“Real” candida

esophagitisBystander

Endoscopy:

Friable, hyperemic mucosa

White plaques to pseudomembranes

(sometimes black)

In advanced cases narrowed esophagus

Clinical history:

Non-specific

Symptoms of underlying disease

Endoscopy:

Usually a non-specific ulcer

Subtle white patch may be present

Inflammatory

infiltrate rich

in Neus

Pseudohyphae

Budding yeasts

“Real” candida

esophagitisBystander

Actinomyces in the esophagus

Usually an innocent bystander

Probably an ingested colony trapped

in an ulcer

Herpetic esophagitis

Clinical history:

Neonates, babies

Immunocompromised

Reactivation in immunocompetent

Acute odynophagia, chest pain, fever

Endoscopy:

Distal half

Vesicles → Punched-out ulcers

↑ → Confluent ulcers

↑ → Haemorrhagic esophagitis

Enlarged ground glass cytoplasm

Cowdry A nuclear inclusions

Multinucleated squamous cells

BUT:

HSV proven by molecular genetics

CMV esophagitis

Clinical history:

Elderly

Debilitated

Immunocompromised

Non-specific symptoms

Endoscopy:

Distal half

Superficial ulcers

Squamous epithelium usually

shows only reactive changes and

inflammatory infiltrate

Eosinophilic intranuclear (and

small basophilic cytoplasmic)

inclusions are found in

endothelial cells, myofibroblasts

and macrophages

Courtesy of Cord Langner, M.D.

Pill esophagitis

Most common pills:

Doxycycline

Iron

Alendronate

Not the real pills:

Kayexalate

(sorbitol)

+ keratosis

+ mykoorganisms

(+ Neus)

Candida

+ viral inclusions Viral esophagitis

+ granulomas

+ distal GIT

involved

Crohn disease

+ parasites Parasitic esophagitis

+ blood Eos >1500/µl >

6 months

+other organs involved

HES

Features favoring EoE over GERD

↑ incidence of allergic diseases

Food impaction common

Dysphagia common

Mucosal rings and furrows common

Ulcers uncommon

pH commonly normal

Distal esophagus less severely affected

No response to PPIs

Response to immunosupression

Eosinophilic esophagitis

Histological signs of EoE

Eos count > 15/HPF (?)

Eo clusters to microabscesses

Degranulation of Eos

Epithelial spongiosis

Subepithelial sclerosis

?

Distal esophagus Proximal esophagus

Other differential dx.

Disease Clues

Eosinophilic gastroenteritis Gastrointestinal eosinophilia

Achalasia Endoscopy, motility studies

Drug hypersensitivity Pharmacological history

Vasculitis Complex symptomatology (and investigation)

Pemphigus Suprabasal clefts, akantholysis, skin manifestation, serology

Connective tissue diseases Complex symptomatology (and investigation)

GvHD Apoptosis, BMT history

Crohn disease

Up to 10% of CD cases

Most commonly pattern of lymphocytic esophagitis

Granulomas reported in up to 40%

Ileocolonic involvement crucial for the diagnosis

Other differential dx.

Sarcoidosis

Mycobacteria

Funghi

Vasculitis

Entity Clues

Corrosive esophagitis

History

Acute acidic: coagulative necrosis

Acute alkaline: liquefactive necrosis

Late stage: fibrosis

Sloughing esophagitis Debilitated patients, superficial coagulative necrosis

GvHD ↑ apoptosis, dyskeratotic keratinocytes, history

Mycophenolate esophagitis ↑ apoptosis, history

Colchicine toxicity Mitotic arrest, history

Taxanes toxicity Mitotic arrest, history

Scleroderma Submucosal fibrosis

Radiation esophagitis

Clinical history:

Dysphagia, odynophagia

Disordered motility

Possible additive effect of chemotherapy

Early findings:

Edematous, hyperemic mucosa

Erosions to ulcers

Degenerative and regenerative changes of

epithelium

Late findings:

Fibrosis

Strictures and webs

Acanthosis, parakeratosis

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