Esophageal Lesions: A High Index of Suspicion is Important for Diagnosis

Jie-Hyun Kim

doi:10.5946/ce.2020.278

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Boost Your Learning with Quiz Esophageal Lesions: A High Index of Suspicion is Important for Diagnosis: Jie-Hyun Kim^,; Clinical Endoscopy 2020;53(6):757-758.
DOI: https://doi.org/10.5946/ce.2020.278
Published online: November 27, 2020

Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea

Correspondence: Jie-Hyun Kim Division of Gastroenterology, Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul 06273, Korea Tel: +82-2-2019-3505, Fax: +82-2-3463-3882, E-mail: otilia94@yuhs.ac

• Received: October 20, 2020 • Revised: November 18, 2020 • Accepted: November 18, 2020

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Quiz

A 55-year-old woman visited the hospital after experiencing heartburn and dysphagia for several months. She underwent endoscopy screening 2 years prior, at which time there were no remarkable findings. This time, endoscopy revealed longitudinal furrows and multiple papilloma-like nodules in the esophagus (Fig. 1). There was no mucosal break at the esophagogastric junction. A biopsy of the esophageal lesions was performed (Fig. 2).

What is the most likely diagnosis?

Answer

Considering the endoscopic and pathologic findings, the diagnosis would be eosinophilic esophagitis (EoE). EoE is an antigen-mediated disease of the esophagus in which chronic eosinophil-rich inflammation promotes symptoms and esophageal dysfunction [1]. EoE is distinguished by several endoscopic characteristics; hence, a high index of suspicion is warranted for endoscopic diagnosis. These characteristics include linear furrows (vertical lines), esophageal rings (concentric rings), edema (decreased vascularity), plaques (white spots, exudates), strictures, and a crepe paper-like esophagus (mucosal fragility) [2]. Hirano et al. proposed an endoscopic classification system for EoE in an attempt to standardize the method of endoscopic diagnosis (Table 1) [3]. Based on this classification, an endoscopic reference scoring system referred to as EREFS (an acronym consisting of exudates, rings, edema, furrows, and strictures) was created.

Endoscopic features play an important role in clinical suspicion, but the diagnosis should ultimately be based on biopsies and histopathology. A biopsy of the regions within the esophagus depicting abnormal findings should be performed. The European guidelines on EoE recommend biopsies of both the proximal and distal halves of the esophagus [4]. In addition, reference biopsies of the stomach and duodenum are necessary to exclude eosinophilic gastroenteritis, a secondary cause of eosinophilic infiltration in the esophagus. EoE is diagnosed when at least 15 eosinophils per HPF are detected. In this case, the biopsy of the esophagus showed significant intraepithelial eosinophilic infiltration of more than 15 eosinophils per HPF.

Conflicts of Interest: The author has no financial conflicts of interest.

Fig. 1.

Endoscopic findings revealed longitudinal furrows and multiple papilloma-like nodules in the esophagus (A, B). There was no mucosal break at the esophagogastric junction (C).

Fig. 2.

Microscopic findings showed significant intraepithelial eosinophilic infiltration more than 15 cells/HPF. (A) Hematoxylin and eosin, ×100. (B) Hematoxylin and eosin, ×400.

Table 1.

Endoscopic Score EREFS for Grading Eosinophilic Esophagitis

Endoscopic findings	Scoring
Exudates	0- Absent
	1- Mild (<10% of the esophageal surface area)
	2- Severe (≥10% of the esophageal surface areas)
Rings	0- Absent
	1- Mild (subtle circumferential ridges)
	2- Moderate (distinct rings)
	3- Severe (rings that impair passage of a standard adult diagnostic endoscope)
Edema	0- Absent
Edema	1- Present (loss of vascular markings)
Furrows	0- Absent
	1- Mild (present but without visible depth)
	2- Severe (visible depth or mucosal indentation)
Strictures	0- Absent
Strictures	1- Present

Adapted from Hirano et al. [3]

REFERENCES

1. Dellon ES, Liacouras CA, Molina-Infante J, et al. Updated international consensus diagnostic criteria for eosinophilic esophagitis: proceedings of the AGREE conference. Gastroenterology 2018;155:1022–1033; e10.Article PubMed PMC
2. Surdea-Blaga T, Popovici E, Fadgyas Stănculete M, Dumitrascu DL, Scarpignato C. Eosinophilic esophagitis: diagnosis and current management. J Gastrointestin Liver Dis 2020;29:85–97.Article PubMed
3. Hirano I, Moy N, Heckman MG, Thomas CS, Gonsalves N, Achem SR. Endoscopic assessment of the oesophageal features of eosinophilic oesophagitis: validation of a novel classification and grading system. Gut 2013;62:489–495.Article PubMed
4. Lucendo AJ, Molina-Infante J, Arias Á, et al. Guidelines on eosinophilic esophagitis: evidence-based statements and recommendations for diagnosis and management in children and adults. United European Gastroenterol J 2017;5:335–358.Article PubMed PMC

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Esophageal Lesions: A High Index of Suspicion is Important for Diagnosis

Clin Endosc. 2020;53(6):757-758. Published online November 27, 2020

DOI: https://doi.org/10.5946/ce.2020.278

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Figure

Esophageal Lesions: A High Index of Suspicion is Important for Diagnosis

Fig. 1. Endoscopic findings revealed longitudinal furrows and multiple papilloma-like nodules in the esophagus (A, B). There was no mucosal break at the esophagogastric junction (C).

Fig. 2. Microscopic findings showed significant intraepithelial eosinophilic infiltration more than 15 cells/HPF. (A) Hematoxylin and eosin, ×100. (B) Hematoxylin and eosin, ×400.

Fig. 1.

Fig. 2.

Esophageal Lesions: A High Index of Suspicion is Important for Diagnosis

Endoscopic findings	Scoring
Exudates	0- Absent
	1- Mild (<10% of the esophageal surface area)
	2- Severe (≥10% of the esophageal surface areas)
Rings	0- Absent
	1- Mild (subtle circumferential ridges)
	2- Moderate (distinct rings)
	3- Severe (rings that impair passage of a standard adult diagnostic endoscope)
Edema	0- Absent
Edema	1- Present (loss of vascular markings)
Furrows	0- Absent
	1- Mild (present but without visible depth)
	2- Severe (visible depth or mucosal indentation)
Strictures	0- Absent
Strictures	1- Present

Table 1. Endoscopic Score EREFS for Grading Eosinophilic Esophagitis

Adapted from Hirano et al. [3]