Non gastro-esophageal reflux disease related esophagitis: an overview with a histologic diagnostic approach

Abstract

Several pathological conditions, other than gastro-esophageal reflux disease and its complications, can affect the esophagus. While some of these can present with unspecific lesions (i.e. ulcers and epithelial damage) and require clinico-pathological correlation for diagnosis (i.e. drug-induced esophagitis and corrosive esophagitis) other conditions show distinctive histological lesions which enable the pathologist to reach the diagnosis (i.e. some specific infectious esophagites and Crohn's disease). In this context eosinophilic esophagitis is the condition which has been increasingly studied in the last two decades, while lymphocytic esophagitis, a relatively new entity, still represents an enigma. This overview will focus on and describe histologic lesions which allow pathologists to differentiate between these conditions.

Keywords: drug-induced esophagitis; eosinophilic esophagitis; esophageal Crohn’s disease; esophagitis dissecans superficialis; lymphocytic esophagitis.

Figure 1.

(A) Cytomegalovirus esophagitis (magnification 40x). Nucleomegaly with intranuclear inclusions (black arrow). (B) Cytomegalovirus esophagitis (magnification 40x). Immunohistochemistry with anti-CMV antibody, showing sparse positive nuclei. (C) Herpes Simplex Virus esophagitis (magnification 10x). Multinucleated giant cells and ground glass intranuclear inclusions (black arrow) with necrotic debris and inflammation. (D) Candida Albicans esophagitis (magnification 20x). Alcian Blu PAS staining showing hyphae and spores on the surface of squamous epithelium.

Figure 2.

(A) Radiation esophagitis (magnification 10x). Ballooning degeneration of squamous epithelium with edema; a vessel with hyalinized wall is present in the submucosal layer. (B) Corrosive esophagitis (magnification 10x) in a patient with accidental ingestion of sodium hydroxide (lye or caustic soda) showing necrosis and inflammation with diffuse ulceration of the mucosa and submucosa. (C) Esophagitis dissecans superficialis (magnification 40x). An intraepithelial cleft (black arrow) is visible with two strips of squamous epithelium showing a different color tone. (D) Black esophagus (magnification 10x). Autopsy finding, revealing necrosis of the esophagus with abundant neutrophils and abundant brown pigmented granules.

Figure 3.

(A) Esophageal Crohn’s disease (magnification 20x). Presence of an epithelioid granuloma within squamous epithelium, diagnostic for esophageal localization of Crohn’s disease in a patient with previous diagnosis in the distal ileum; (B) Eosinophilic esophagitis (magnification 40x). A high number of intraepithelial eosinophils is present, also forming microabscesses (black arrow) in the superficial layer. (C) Lymphocytic esophagitis (magnification 40x). Marked spongiosis is present with an increase in intraepithelial lymphocytes in the peri-papillary areas. (D) Lymphocytic esophagitis (magnification 40x). Immunostains for CD3 showing a marked increase in intraepithelial T lymphocytes.