Clinical Endoscopy

The Korean Society of Gastrointestinal Endoscopy (대한소화기내시경학회)
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Analysis of the Clinicopathologic Features of Eosinophilic Esophagitis: Comparative Study with Nonobstructive Dysphagia

호산구 식도염의 임상병리학적 특징 분석: 비폐쇄성 연하곤란과의 비교 연구

  • Kim, Kwang-Hyun (Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine) ;
  • Chung, Il-Hyung (Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine) ;
  • Kim, Jie-Hyun (Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine) ;
  • Youn, Young-Hoon (Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine) ;
  • Yoon, Sun-Och (Department of Pathology, Gangnam Severance Hospital, Yonsei University College of Medicine) ;
  • Park, Hyo-Jin (Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine) ;
  • Lee, Sang-In (Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine)
  • 김광현 (연세대학교 의과대학 강남세브란스병원 소화기내과학교실) ;
  • 정일형 (연세대학교 의과대학 강남세브란스병원 소화기내과학교실) ;
  • 김지현 (연세대학교 의과대학 강남세브란스병원 소화기내과학교실) ;
  • 윤영훈 (연세대학교 의과대학 강남세브란스병원 소화기내과학교실) ;
  • 윤선옥 (연세대학교 의과대학 강남세브란스병원 병리학교실) ;
  • 박효진 (연세대학교 의과대학 강남세브란스병원 소화기내과학교실) ;
  • 이상인 (연세대학교 의과대학 강남세브란스병원 소화기내과학교실)
  • Published : 2011.03.30
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Abstract

Background/Aims: Eosinophilic esophagitis (EoE) has emerged as one of the most common causes of dysphagia and esophageal food impactions. However, it is doubtful that gastroenterologists and pathologists make the correct diagnosis of EoE because of the insufficient recognition of EoE based on the endoscopic and pathological findings. This study was performed to investigate the symptoms and the endoscopic and pathologic findings of EoE as compared with those of nonobstructive dysphagia (NOD). Methods: We retrospectively reviewed the medical records and the endoscopic and pathologic findings from 12 patients who were diagnosed with EoE based on an eosinophil count of ${\geq}$20 per high-power field (HPF) and 13 patients diagnosed with NOD, and these patients were treated at our hospital from June 2006 till October 2010. Results: The endoscopic findings of EoE included rings (41.7%), furrows (75.0%), exudates (33.3%), mucosal friability (8.3%) and multi-findings (6.7%). Furrows and multi-findings were identified more frequently in EoE as comparison to that in NOD. The pathologic findings revealed that the maximal eosinophil counts/HPF were 87.2 (range 20~232) and 2.2 (0~11) in EoE and NOD, respectively. Moreover, eosinophil microabscess (58.3%), degranulation (100%) and spongiosis (91.7%) were more significantly observed in EoE compared with that in NOD. Conclusions: EoE had specific endoscopic and clinicopathologic features that distinguish it from NOD. For patients with dysphagia, the endoscopic and pathologic findings of EoE should be kept in mind.

목적: 호산구 식도염(eosinophilic esophagitis, EoE)은 식도의 과도한 호산구 침윤으로 인하여 연하 곤란 등의 증상을 일으키는 드문 질환이나, 최근 유병률이 증가하고 있다. 그러나 아직도 이에 대한 임상적, 병리적 인지 부족으로 인하여 진단이 적절히 이루어지지 않고 있다. 저자들은 비폐쇄성 연하곤란(nonobstructive dysphagia, NOD) 환자의 임상 증상, 내시경, 식도 조직의 병리 소견과의 비교를 통하여 EoE의 내시경 소견 및 임상병리적 특징을 고찰하였다. 대상 및 방법: 2006년 6월부터 2010년 10월까지 강남세브란스 병원에서 내시경을 받은 환자들 중, EoE로 진단된 12명과 연하곤란으로 식도 조직검사를 받은 NOD 13명을 대상으로 하였다. EoE의 진단은 식도 조직검사 상 고배율 시야 당 호산구가 20개 이상 관찰되는 것으로 하였으며, 양 군의 내시경 소견과 병리 슬라이드를 후향적으로 재검토하여 병리 소견을 비교하였다. 결과: EoE의 내시경 소견은 원형 주름(41.7%), 골(75%), 삼출물(33.3%), 점막 취약성(8.3%), 2개 이상의 소견(6.7%)이었으며, 이 중 골과 2개 이상의 소견은 통계학적으로 유의하게 NOD보다 많이 관찰되었다. 고배율 시야당 호산구의 개수는 EoE에서 87.2개(20~232개)로 NOD에서 2.2개(0~11개)에 비해 유의하게 많았다. 또한, EoE에서 호산구 미세농양(7명 대 0명; p<0.01), 호산구 탈과립(12명 대 1명; p<0.01), 해면화 (11명 대 5명; p=0.01)가 유의하게 많았다. 그러나 고유판 유두부 길이 증가, 섬유화, 기저 세포층 증식은 유의한 차이가 없었다. 결론: 본 연구에서 EoE는 NOD와 구별되는 명확한 내시경 소견 및 임상병리적 특징들을 보였다. 연하곤란의 환자에 대한 접근에 있어 이러한 EoE의 특징을 숙지하는 것이 EoE의 진단에 도움이 되리라 생각한다.

Keywords

References

  1. Furuta GT, Liacouras CA, Collins MH, et al. Eosinophilic esophagitis in children and adults: a systematic review and consensus recommendations for diagnosis and treatment. Gastroenterology 2007;133:1342-1363. https://doi.org/10.1053/j.gastro.2007.08.017
  2. Park H. Eosinophilic esophagitis. Korean J Gastroenterol 2007;50:286-291.
  3. Winter HS, Madara JL, Stafford RJ, Grand RJ, Quinlan JE, Goldman H. Intraepithelial eosinophils: a new diagnostic criterion for reflux esophagitis. Gastroenterology 1982;83:818-823.
  4. Attwood SE, Smyrk TC, Demeester TR, Jones JB. Esophageal eosinophilia with dysphagia. A distinct clinicopathologic syndrome. Dig Dis Sci 1993;38:109-116. https://doi.org/10.1007/BF01296781
  5. Kapel RC, Miller JK, Torres C, Aksoy S, Lash R, Katzka DA. Eosinophilic esophagitis: a prevalent disease in the United States that affects all age groups. Gastroenterology 2008;134:1316-1321. https://doi.org/10.1053/j.gastro.2008.02.016
  6. Dellon ES, Aderoju A, Woosley JT, Sandler RS, Shaheen NJ. Variability in diagnostic criteria for eosinophilic esophagitis: a systematic review. Am J Gastroenterol 2007;102:2300-2313. https://doi.org/10.1111/j.1572-0241.2007.01396.x
  7. Arora AS, Yamazaki K. Eosinophilic esophagitis: asthma of the esophagus? Clin Gastroenterol Hepatol 2004;2:523-530. https://doi.org/10.1016/S1542-3565(04)00236-8
  8. Kanakala V, Lamb CA, Haigh C, Stirling RW, Attwood SE. The diagnosis of primary eosinophilic oesophagitis in adults: missed or misinterpreted? Eur J Gastroentrol Hepatol 2010;22:848-855. https://doi.org/10.1097/MEG.0b013e32832c7709
  9. Sgouros SN, Bergele C, Mantides A. Eosinophilc esophagitis in adults: a systematic review. Eur J Gastroenterol Hepatol 2006;18:211-217. https://doi.org/10.1097/00042737-200602000-00015
  10. Gonsalves N, Policarpio-Nicolas M, Zhang Q, Rao MS, Hirano I. Histopathologic variability and endoscopic correlates in adults with eosinophilic esophagitis. Gastrointest Endosc 2006;64:313-319. https://doi.org/10.1016/j.gie.2006.04.037
  11. Patel N, Busler JF, Geisinger K, Geisinger K, Hill I. Are pathologists accurately diagnosing eosinophilic esophagitis in children? A 9-year single academic institutional experience with interobserver observations. Int J Surg Pathol 2010. [Epub ahead of print]
  12. Rodrigo S, Abboud G, Oh D, et al. High intraepithelial eosinophil counts in esophageal squamous epithelium are not specific for eosinophilic esophagitis in adults. Am J Gastroenterol 2008;103:435-442. https://doi.org/10.1111/j.1572-0241.2007.01594.x
  13. Kim JW, Park JS, Kim YH, et al. Secondary achalasia by eosionphilic esophagitis. Korean J Gastrointest Endosc 2002;25:198-202.
  14. Yu YH, Jo YJ, Jung MY, et al. Prevalence of eosinophilic esophagitis with dysphagia and reflux related symptoms in Korean patients. Korean J Neurogastroenterol Motil 2009;15:15-22.
  15. Lee B, Park H, Yoon H, Kim HK, Kim HS. Three cases of eosinophilic esophagitis with dysphagia as a chief complaint. Korean J Gastrointest Endosc 2008;36:145-149.
  16. Jung YM, Lee HS, Lee DH, et al. Clinical significance of incidentally detected eosinophilic esophagitis with pathologic review. Korean J Gastroenterol 2010;55:162-168. https://doi.org/10.4166/kjg.2010.55.3.162
  17. Robbins J, Langmore S, Hind JA, Erlichman M. Dysphagia research in the 21st century and beyond: proceedings from Dysphagia Experts Meeting, August 21, 2001. J Rehabil Res Dev 2002;39:543-548.
  18. Veerappan GR, Perry JL, Duncan TJ, et al. Prevalence of eosinophilic esophagitis in an adult population undergoing upper endoscopy: a prospective study. Clin Gastroenterol Hepatol 2009;7:420-426. https://doi.org/10.1016/j.cgh.2008.10.009
  19. Sgouros SN, Bergle C, Mantides A. Eosinophilic esophagitis in adults: what is the clinical significance? Endoscopy 2006;38:515-520. https://doi.org/10.1055/s-2006-924983
  20. Dellon ES, Gibbs WB, Fritchie KJ, et al. Clinical, endoscopic, and histologic findings distinguish eosinophilic esophagitis from gastroesophageal reflux disease. Clin Gastroenterol Hepatol 2009;7:1305-1313. https://doi.org/10.1016/j.cgh.2009.08.030
  21. Straumann A, Spichtin HP, Grize L, Bucher KA, Beglinger C, Simon HU. Natural history of primary eosinophilic esophagitis: a follw-up of 30 adult patients for up to 11.5 years. Gastroenterology 2003;125:1660-1669. https://doi.org/10.1053/j.gastro.2003.09.024
  22. Park SB, Kim GH, Choi MK, et al. A case of eosinophilic esophagitis found incidentally during the evaluation of a gastric submucosal tumor. Korean J Gastrointest Endosc 2009;39:212-216.
  23. Straumann A, Bussmann C, Zuber M, Vannini S, Simon HU, Schoepfer A. Eosinophilic esophagitis: analysis of food impaction and perforation in 251 adolescent and adult patients. Clin Gastroenterol Hepatol 2008;6:598-600. https://doi.org/10.1016/j.cgh.2008.02.003
  24. Potter JW, Saeian K, Staff D, et al. Eosinophilic esophagitis in adults: an emerging problem with unique esophageal features. Gastrointest Endosc 2004;59:355-361. https://doi.org/10.1016/S0016-5107(03)02713-5
  25. Croese J, Fairley SK, Masson JW, et al. Clinical and endoscopic features of eosinophilic esophagitis in adults. Gastrointest Endosc 2003;58:516-522. https://doi.org/10.1067/S0016-5107(03)01870-4
  26. Desai TK, Stecevic V, Chang CH, Goldstein NS, Badizadegan K, Furuta GT. Association of eosinophilic inflammation with esophageal food impaction in adults. Gastrointest Endosc 2005;61:795-801. https://doi.org/10.1016/S0016-5107(05)00313-5
  27. Antonioli DA, Furuta GT. Allergic eosinophilic esophagitis: a primer for pathologists. Semin Diagn Pathol 2005;22:266-272. https://doi.org/10.1053/j.semdp.2006.05.002
  28. Odze RD. Pathology of eosinophilic esophagitis: what the clinician needs to know. Am J Gastroenterol 2009;10:485-490.
  29. Lee S, de Boer WB, Naran A, et al. More than just counting eosinophils: proximal oesophageal involvement and subepithelial sclerosis are major diagnostic criteria for eosinophilic oesophagitis. J Clin Pathol 2010;63:644-647. https://doi.org/10.1136/jcp.2010.078402
  30. Parfitt JR, Gregor JC, Suskin NG, Jawa HA, Driman DK. Eosinophilic esophagitis in adults: distinguishing features from gastroesophageal reflux disease: a study of 41 patients. Mod Pathol 2006;19:90-96.
  31. Mueller S, Aigner T, Neureiter D, Stolte M. Eosinophil infiltration and degranulation in oesophageal mucosa from adult patients with eosinophilic oesophagitis: a retrospective and comparative study on pathological biopsy. J Clin Pathol 2006;59:1175-1180. https://doi.org/10.1136/jcp.2005.031922
  32. Steiner SJ, Kernek KM, Fitzgerald JF. Severity of basal cell hyperplasia differs in reflux versus eosinophilic esophagitis. J Pediatr Gastroenterol Nutr 2006;42:506-509. https://doi.org/10.1097/01.mpg.0000221906.06899.1b
  33. Chehade M, Sampson HA, Morotti RA, Magid MS. Esophageal subepithelial fibrosis in children with eosinophilic esophagitis. J Pediatr Gastroenterol Nutr 2007;45:319-328. https://doi.org/10.1097/MPG.0b013e31806ab384
  34. Straumann A, Simon HU. The physiological and pathophysiological roles of eosinophils in the gastrointestinal tract. Allergy 2004;59:15-25. https://doi.org/10.1046/j.1398-9995.2003.00382.x
  35. Atkins D, Kramer R, Capocelli K, Lovell M, Furuta GT. Eosinophilic esophagitis: the newest esophageal inflammatory disease. Nat Rev Gastroenterol Hepatol 2009;6:267-278. https://doi.org/10.1038/nrgastro.2009.45
  36. Yam BM, Shaffer EA. Primary eosinophilic disorders of the gastrointestinal tract. Gut 2009;58:721-732. https://doi.org/10.1136/gut.2008.165894
  37. Abonia JP, Blanchard C, Butz BB, et al. Involvement of mast cells in eosinophilic esophagitis. J Allergy Clin Immunol 2010;126:140-149. https://doi.org/10.1016/j.jaci.2010.04.009