Eosinophilic esophagitis

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Histopathology of eosinophilic esophagitis, showing multiple intraepithelial eosinophils (bilobed cells with eosinophilic cytoplasm on H&E stain), and edema seen as white clearings.

Author:

Mikael Häggström [note 1]

Comprehensiveness

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Microscopic diagnosis

An intra-epithelial eosinophil (characterized by its bilobed nucleus despite scant visible eosinophilic cytoplasm)

It is characterized by a prominent eosinophilic infiltrate in the esophagus. Count in at least one high power field of an intraepithelial area where there may be the highest concentration of eosinophils, and count them. Only count eosinophils where you see the nucleus. If you know your high power field (HPF) is about 0.25 mm2, diagnose it if you see over 15 intra-epithelial eosinophils per HPF.[1] [note 2] If your HPF is significantly different, or if you are not sure, diagnose it at over 60 eosinophils/mm2. Further information: Evaluation

(Also look for other "minor criteria" associated with eosinophilic esophagitis: extreme basal zone hyperplasia with papillary hyperplasia, eosinophils concentrated in the surface epithelium as opposed to the base, eosinophilic microabscesses, eosinophil degranulation, surface desquamation, lamina propria fibrosis.[2])

Further workup

For cases of eosinophilic esophagitis, also look for any fungal organisms.

Report

  • If positive:
  • Presence of eosinophilic esophagitis, or findings consistent thereof
  • Number of eosinophils per HPF
  • (Presence or absence of fungal organisms)

Example in a positive case:

Squamous mucosa with increased intraepithelial eosinophils (up to 80 per high-power field)(, consistent with eosinophilic esophagitis.
Negative for fungal organisms (H&E stained slide). See comment.)

(Comment: Increased numbers of intraepithelial eosinophils in the squamous mucosa can be found in both reflux esophagitis and eosinophilic esophagitis. Although clinical correlation is recommended, some secondary histologic features favor eosinophilic esophagitis.)

In borderline cases, such as an incidental finding of eosinophils at around 15/HPF:

(Esophagus, biopsy:)
Squamous mucosa with increased intraepithelial eosinophils of up to 15/HPF. See comment.
...

Comment: There is no evidence of eosinophilic microabscesses. Although this may represent reflux esophagitis, a diagnosis of eosinophilic esophagitis is considered in the correct clinical setting.

Notes

  1. For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Patholines:Authorship for details.
  2. It has also been described as ≥15 intraepithelial eosinophils in ≥2 hpfs or ≥25 in any single hpf.
    - Parfitt, Jeremy R; Gregor, James C; Suskin, Neville G; Jawa, Hani A; Driman, David K (2005). "Eosinophilic esophagitis in adults: distinguishing features from gastroesophageal reflux disease: a study of 41 patients ". Modern Pathology 19 (1): 90–96. doi:10.1038/modpathol.3800498. ISSN 0893-3952. 

Main page

References

  1. Dellon, Evan S. (2012). "Eosinophilic esophagitis ". Current Opinion in Gastroenterology 28 (4): 382–388. doi:10.1097/MOG.0b013e328352b5ef. ISSN 0267-1379. 
  2. Ryan C. Braunberger, M.D., Joshua A. Hanson, M.D.. Eosinophilic esophagitis. Pathology Outlines. Last staff update: 20 December 2022

Image sources