Lymphocytic esophagitis confirmed as ‘emerging condition’
MedWire News: Lymphocytic esophagitis (LyE) occurs in around one in a 1000 patients who undergo esophageal biopsy, say US researchers who found the emerging condition is associated with dysphagia and other symptoms.
"If recognised and reported by histopathologists, more gastroenterologists will become aware of this entity and may ultimately discover aetiological associations and therapies," say Salima Haque and Robert Genta, from the University of Texas Southwestern Medical Center in Dallas.
Although lymphocyitc esophagitis has been linked to pediatric Crohn's disease, the prevalence and pattern in adults is unclear, they observe in the journal Gut.
To investigate further, the researchers reviewed archive endoscopy biopsy results for patients examined 2007-2009. Initially, LyE was defined as increased intraepithelial lymphocytes or features suggestive of LyE, such as patchy peripapillary lymphocytic infiltrates with a density of at least 125 lymphocytes per mm2.
Overall, 42 patients (26 women), median age 52 years, met this criteria. Most patients underwent endoscopy for dysphagia or odynophagia (71.4%) or gastroesophageal reflux disorder (26.2%).
Endoscopy reveal normal esophagus in 21.4% of patients, distal esophagitis in 31.0%, esinophilic esophagitis in 31.0%, and strictures in 9.5%. A further 8.8% had decreased motility.
Lymphocyte count in 20 patients with intestinal Crohn's disease was 16 per mm2 (maximum 63 per mm2). Among 100 healthy individuals, lymphocytes were undetected in 26 participants, and the mean was 22 per mm2 (maximum 50 mm2).
The researchers report that because lymphocytic infiltrates in patients were patchy, with few lymphocytes in some areas and over 100 lymphocytes in affected peripapillary zones, they recommend that LyE should not be defined by a minimum density of lymphocytes.
Instead, they suggest LyE diagnosis should be made by the presence of dense peripapillary lymphocyte infiltrates, peripapillary spongiosis in the lower two-thirds of the epithelium, and the absence of neutrophil or eosinophil infiltrates.
Next, the researchers disseminated this histopathologic criteria for the condition among gastroenterology pathologists in the USA. After 18 months, the team collated information on reported cases and compared the findings with those patients with eosinophilic esophagitis (EoE) or normal esophageal tissue.
Of 129,252 patients examined, 40,665 had normal mucosa, 3745 had EoE, and 119 patients had LyE.
Patients with LyE were predominantly female (60%) and aged a median of 63 years, whereas EoE patients were predominantly male (66%) and aged a median of 43 years. The majority of patients with a healthy biopsy were female (68% ), with a median age of 55 years.
Analysis showed that patients with LyE were as likely as those with EoE to have dysphagia (53% vs 63%), and both were less likely than patients with a healthy biopsy to have gastroesophageal reflux disorder (37 vs 18 and 19%, respectively).
A third of patients with LyE had endoscopic features suggestive of EoE, such as "felinisation" with furrows, whitish plaques, and strictures.
Noting that patients with LyE were often treated as for reflux esophagitis, and that follow-up studies were not performed, the team concludes: "The clinical significance of this constellation of histopathologic findings that we are calling [LyE] remains elusive."
Haque and Genta comment: "Considering the indolent clinical response to a diagnosis of lymphocytic oesophagitis, pathologists might want to consider contacting the clinicians directly to discuss the findings and the possible significance in each case."
MedWire (http://www.medwire-news.md/) is an independent clinical news service provided by Springer Healthcare Limited. © Springer Healthcare Ltd; 2011
By Lynda Williams