Evaluation of peripapillary lymphocytosis and lymphocytic esophagitis in adult inflammatory bowel disease

Abstract

Lymphocytic esophagitis (LE) is a newly described entity characterized histopathologically by peripapillary lymphocytosis (PL) without significant granulocytes (neutrophils and eosinophils). In an initial study, a significant portion of patients with LE had Crohn's disease (CD). A subsequent study revealed LE in one quarter of children with CD. The aim of this study was to test the hypothesis that LE is associated with adult inflammatory bowel disease (IBD) and assess the disease variables that link LE and IBD. Random esophageal biopsies from consecutive adults with CD, ulcerative colitis (UC), or indeterminate colitis (IC) were evaluated. The numbers of lymphocytes, eosinophils, and neutrophils were counted from 3 high-power fields (HPF) in each specimen. Four of 47 patients (8.5%; 3/30 CD, 1/15 UC, and 0/2 IC) had PL (esophageal biopsies with ≥50 lymphocytes/HPF; mean, 100.5±31.1/HPF). A significant number of granulocytes were seen in biopsies from 3 of the 4 patients with PL, leaving 1 who met criteria for LE (PL without significant granulocytes). PL was associated with a higher erythrocyte sedimentation rate (90.3±17.6 mm/hr vs 24.5±3.6 mm/hr; P<.001) and C-reactive protein level (5.5±2.2 mg/dL vs 1.0±0.2 mg/dL; P<.001), with risk ratios of 2.06 (95% confidence interval [CI], 1.45-2.93; P=.031) and 3.56 (95% CI, 2.04-6.19; P=.033), respectively, for elevated values. All patients with PL had a relapsing CD course. The mean Harvey-Bradshaw index (HBI) was higher in these patients (8.5±0.6 vs 4.3±0.7; P=.026), with a risk ratio of 4.78 for moderate-to-severe disease (95% CI, 2.67-8.54; P=.004). We found a less frequent association between IBD and LE than was previously reported. This may be due to differences between pediatric and adult IBD. Alternatively, it may be methodologic because, unlike in previous reports, we evaluated consecutive patients with IBD. PL was associated with elevated inflammatory markers and HBI. These observations suggest that PL may be a marker of disease activity in IBD.

Keywords: Crohn’s disease; esophagitis; inflammatory bowel disease; lymphocytes; lymphocytic esophagitis; ulcerative colitis.

Figure 1

Low-power (A) and high-power (B) photomicrographs of peripapillary lymphocytosis. Note the peripapillary infiltrative pattern (hematoxylin and eosin stain).

Figure 2

Markers of inflammation and disease activity associated with peripapillary lymphocytosis (PL). HBI, ESR (mm/hr), and CRP level (mg/dL) were significantly higher in subjects with PL. All subjects with PL had elevated ESR and CRP levels. Comparisons were made by Student t test. CRP, C-reactive protein; ESR, erythrocyte sedimentation rate; HBI, Harvey-Bradshaw index; HPF, high-power field.