Overlap of reflux and eosinophilic esophagitis in two patients requiring different therapies: a review of the literature

Abstract

Eosinophilic esophagitis (EE) and gastroesophageal reflux disease (GERD) have overlapping clinical, manometric, endoscopic and histopathologic features. The diagnosis of EE is nowadays based upon the presence of 15 or more eosinophils per high power field (eo/HPF) in esophageal biopsies. We report the cases of two young males suffering from dysphagia and recurrent food impaction with reflux esophagitis and more than 20 eo/HPF in upper-mid esophagus biopsies, both of which became asymptomatic on proton pump inhibitor (PPI) therapy. The first patient also achieved a histologic response, while EE remained in the other patient after effective PPI treatment, as shown by 24-h esophageal pH monitoring. Topical steroid therapy combined with PPI led to complete remission in this latter patient. GERD and EE may be undistinguishable, even by histology, so diagnosis of EE should only be established after a careful correlation of clinical, endoscopic and pathologic data obtained under vigorous acid suppression. These diagnostic difficulties are maximal when both diseases overlap. Limited data are available about this topic, and the interaction between EE and GERD is a matter of debate. In this setting, upper-mid esophagus step biopsies and esophageal pH monitoring of patients on PPI therapy are pivotal to evaluate the role of each disease. A PPI trial is mandatory in patients with a histopathologic diagnosis of EE; in those unresponsive to PPI treatment, EE should be suggested. However, a clinical response to PPI may not rule out quiescent EE, as shown in this report.

Figure 1

Case 1. A: Emergency endoscopy showing a meat bolus impacted at mid-distal esophagus with normal mucosa; B: Esophageal manometry demonstrated that two thirds of all contractions in the distal esophagus were simultaneous or interrupted contraction waves; C: Prominent eosinophil microabscesses in upper-mid esophagus biopsies (HE, × 100). In the box and on top of the image, a dense eosinophilic infiltrate (31eo/HPF × 400) predominantly spread over the superficial layers can be observed (HE, × 200); D: Normal upper-mid squamous epithelium after PPI therapy (HE, × 100).

Figure 2

Case 2. A: Endoscopic view of the upper esophagus showing multiple concentric rings resembling mucosal undulations; B: Endoscopic picture of a peptic stricture at cardias 2 mo after dilation, with gentle pressure of the endoscope; C: Biopsies of a multiringed esophagus demonstrating severe lamina propia fibrosis at the bottom of the image, as well as marked papillae elongation and basal zone hyperplasia (HE, × 100). In the upper right box, intense intercellular edema, basal zone hyperplasia and dense eosinophilic infiltrate (37eo/ HPF, × 400) towards the surface strata (HE, × 200); D: Persistent histopathologic features (32 eo/HPF, × 400) in spite of effective PPI therapy, as shown by 24 h pH esophageal monitoring (box).