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Lymphocytic Esophagitis: Still an Enigma a Decade Later

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Lymphocytic Esophagitis: Still an Enigma a Decade Later Submit a Manuscript: http://www.wjgnet.com/esps/ World J Gastroenterol 2017 February 14; 23(6): 949-956 Help Desk: http://www.wjgnet.com/esps/helpdesk.aspx ISSN 1007-9327 (print) ISSN 2219-2840 (online) DOI: 10.3748/wjg.v23.i6.949 © 2017 Baishideng Publishing Group Inc. All rights reserved. MINIREVIEWS Lymphocytic esophagitis: Still an enigma a decade later Carol Rouphael, Ilyssa O Gordon, Prashanthi N Thota Carol Rouphael, Department of General Internal Medicine, Abstract Cleveland Clinic Foundation, Cleveland, OH 44195, United States Lymphocytic esophagitis (LE) is a clinicopathologic entity first described by Rubio et al in 2006. It is defined Ilyssa O Gordon, Department of Pathology, Cleveland Clinic as peripapillary intraepithelial lymphocytosis with Foundation, Cleveland, OH 44195, United States spongiosis and few or no granulocytes on esophageal biopsy. This definition is not widely accepted and the Prashanthi N Thota, Department of Gastroenterology and number of lymphocytes needed to make the diagnosis Hepatology, Digestive Disease and Surgery Institute, Cleveland varied in different studies. Multiple studies have Clinic Foundation, Cleveland, OH 44195, United States described potential clinical associations and risk factors for LE, such as old age, female gender and smoking Author contributions: All authors contributed to this paper with conception and design of the study, literature review and analysis, history. This entity was reported in inflammatory bowel drafting, revision and final approval of the manuscript. disease in the pediatric population but not in adults. Other associations include gastroesophageal reflux Conflict-of-interest statement: All authors have no conflict of disease and primary esophageal motility disorders. The interest. most common symptom is dysphagia, with a normal appearing esophagus on endoscopy, though esophageal Open-Access: This article is an open-access article which was rings, webs, nodularities, furrows and strictures have selected by an in-house editor and fully peer-reviewed by external been described. Multiple treatment modalities have reviewers. It is distributed in accordance with the Creative been used such as proton pump inhibitors and topical Commons Attribution Non Commercial (CC BY-NC 4.0) license, steroids. Esophageal dilation seems to be therapeutic which permits others to distribute, remix, adapt, build upon this when dysphagia is present along with esophageal work non-commercially, and license their derivative works on narrowing secondary to webs, rings or strictures. The different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons. natural history of the disease remains unclear and org/licenses/by-nc/4.0/ needs to be better delineated. Overall, lymphocytic esophagitis seems to have a chronic and benign course, Manuscript source: Invited manuscript except for two cases of esophageal perforation in the literature, thought to be secondary to this entity. Correspondence to: Prashanthi N Thota, MD, FACG, Director, Esophageal Center, Department of Gastroenterology Key words: Lymphocytic esophagitis; Intraepithelial and Hepatology, Digestive Disease and Surgery Institute, lymphocytes; Spongiosis; Gastroesophageal reflux Cleveland Clinic Foundation, Cleveland, OH 44195, disease; CD4 T-cells; Dysphagia; Inflammatory bowel United States. [email protected] disease; Esophageal rings; Proton pump inhibitors; Telephone: +1-216-4440780 Esophageal dilation Fax: +1-216-4454222 © The Author(s) 2017. Published by Baishideng Publishing Received: October 24, 2016 Group Inc. All rights reserved. Peer-review started: October 27, 2016 First decision: December 2, 2016 Revised: December 14, 2016 Core tip: Lymphocytic esophagitis has recently been Accepted: January 18, 2017 described in 2006 and subsequently, multiple groups Article in press: January 18, 2017 have attempted to describe its clinical associations Published online: February 14, 2017 and risk factors with minimal information available on WJG|www.wjgnet.com 949 February 14, 2017|Volume 23|Issue 6| Rouphael C et al . Lymphocytic esophagitis treatment. We performed a PubMed search of all case matory process. A normal esophageal mucosa has a reports and retrospective studies published in English small number of dispersed lymphocytes, mostly with about lymphocytic esophagitis. The objective of this irregular nuclear contours, and mainly in the peripapil- paper is to present a scientific review of all aspects of lary epithelium[9]. An acceptable count of IELs in a this emerging clinical entity known to date. normal esophagus was reported to be 10 IELs/HPF[10]. The lymphocytic population in the esophagus is part of the gut-associated lymphoid tissue: Cytotoxic CD8+ Rouphael C, Gordon IO, Thota PN. Lymphocytic esophagitis: T cells are normally seen in the squamous epithelium Still an enigma a decade later. World J Gastroenterol 2017; along with Langerhans cells. Helper CD4+ T cells and 23(6): 949-956 Available from: URL: http://www.wjgnet. [11] B lymphocytes reside in the lamina propria . com/1007-9327/full/v23/i6/949.htm DOI: http://dx.doi. Given that LE is defined as an increased number of org/10.3748/wjg.v23.i6.949 IELs, we would expect a peripapillary predominance of cytotoxic CD8+ T cells in the esophageal squamous epithelium. This has been inconsistent however, and a recent study demonstrated a CD4+ T-cell-predominant INTRODUCTION intraepithelial lymphocytosis in patients with primary Lymphocytic esophagitis (LE) is a new clinicopathologic esophageal motility disorder (PEMD) raising the possi- entity that was first described by Rubio et al[1] in bility of a new clinicopathologic entity that they labeled 2006 and subsequently, more frequently diagnosed “dysmotility-associated LE”[12]. In contrast, in cases and reported by clinicians and pathologists over the of LE in patients with normal esophageal motility, the last decade. It consists of peripapillary intraepithelial number of CD4+ and CD8+ T lymphocytes varied. lymphocytes (IELs) with no or rare granulocytes on Indeed, one study found a CD8+ T-cell predominance esophageal biopsies. Despite LE being an emerging when LE was associated with GERD in the absence of entity, esophageal IELs have been described years ago PEMD[13]. A better immunophenotypic characterization and several studies, as early as the 1970s, suggested of LE is hence needed for a superior definition. Another a possible association between gastroesophageal reflux aspect of deficiency in the definition of LE is reflected disease (GERD) and an increased number of IELs[2]. in the various studies performed with different cut-offs The co-occurrence of lymphocytes and granulocytes used to demarcate an increased IEL count, ranging in reflux esophagitis has also been reported[2-4]. IELs between ≥ 10 IEL/HPF[14] and ≥ 50 IEL/HPF[15,16] with with irregular nuclear contours were described on the a cut off of ≥ 20 IEL/HPF being commonly used[17,18]. esophageal biopsy specimens of patients with reflux Moreover, the acceptable number of a “few granu- esophagitis[4]. In the late 1990s, Wang et al[5] found locytes” needs to be better defined, as granulocytic that IELs were not an independent marker of reflux inflammation is typically seen in GERD. esophagitis as no correlation was noted between the number of neutrophils and T lymphocytes, despite the presence of a correlation between the number CLinicAL FEAturES OF LE of T lymphocytes and eosinophils. Around that time, The incidence of LE has been on the rise in the United in a Swedish study looking for Menetrier’s disease States over the past few years. It is unclear whether and varioliform lymphocytic gastritis in baboons, one this is true increase in incidence or simply secondary esophageal biopsy specimen was noted to be infiltrated to the condition being better recognized by patholo- by lymphocytes with round irregular contours and a gists and clinicians. In one study of 81 subjects with lack of granulocytes[6]. The latter study was the basis LE, 81.5% were diagnosed between 2006 and 2009 for Rubio’s group to start looking for human biopsy as compared to 6.2% diagnosed between 1998 specimens with similar characteristics and describe LE and 2001[18]. It has been published that LE is being for the first time. They characterized this condition by detected at a rate of 1 in a 1000 on endoscopies and heavy peripapillary intraepithelial lymphocytic infiltra- biopsies performed in the outpatient setting[7]. It is tion with no or rare granulocytes[1]. Consequently, also unclear whether LE is more commonly seen in multiple studies done on LE noted intercellular edema the western world or developing countries. Despite the known as spongiosis[7,8] on pathology slides, a criterion fact that a Swedish group first characterized it, most that was later added to Rubio et al definition. The published case reports and studies looking for clinical widely accepted definition for lymphocytic esophagitis associations and potential risk factors took place in the is increased peripapillary IELs by more than 20 IELs United States. To the best of our knowledge, only three per high power field with little or no granulocytes, case reports in the English literature described cases along with spongiosis (Figure 1). of LE outside the United States, including Japan[19], Portugal[20] and Australia[21]. In contrast to the findings of Rubio et al[1], it is becoming evident that LE seems HistoPAthoLOGY to affect older women to a larger extent, in
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