Lymphocytic Esophagitis is Uncommon 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 the esophageal epithelium. It calls into questions the role of lymphocytes (lymphs) in esophageal inflammation. In an initial study, a significant portion of patients with LE suffered from Crohn's Disease (CD). A subsequent study revealed LE in 1/4 of children with CD. Aim: To test the hypothesis that LE is associated with adult IBD, and to evaluate for disease variables linking them. Methods: Random esophageal biopsies obtained prospectively from consecutive adults with CD, ulcerative colitis (UC), or indeterminate colitis (IC) were evaluated. Numbers of lymphs, eosinophils, and neutrophils were counted from 3 highpower fields (HPF) in each specimen. Specimens with > 50 lymphs in > 1 HPF were evaluated for features of LE. Associations with age, gender, lifestyle, co-morbidities, and lab data were evaluated. Results: Four of 47 patients (8.5%; 3/30 CD, 1/15 UC, 0/2 IC) had esophageal biopsies with >50 lymphs/HPF (mean 100.5±31.0/HPF). A significant number of granulocytes were seen in biopsies from 3 of the 4 patients, leaving only 1 patient who met the strict criteria for LE. Peripapillary lymphocytosis was associated with elevated ESR (90.3±17.6 vs. 24.5±3.6 mm; p<0.001) and CRP (5.5±2.2 vs. 1.0±0.2 mg/dL; p<0.001); all patients with PL had elevated ESR and CRP. Endoscopic findings in patients with PL included white plaque (n=2) and friable mucosa (n=1). Primary characteristics, disease markers, history of alcohol or tobacco use, and co-morbidities were similar in patients with and without PL. All patients with PL had a relapsing CD course (3 with active disease) and CD phenotypes included inflammatory (n=2), penetrating (n=2), and structuring/penetrating (n=1). Three patients (75%) with PL had a clinical history consistent with GERD (8% in patients without PL; p=0.050). Symptoms in patients with PL included odynophagia (n=1), abdominal pain (n=3), and diarrhea (n=1). Active duodenitis and colitis were each present in two patients with PL, one patient had duodenal lymphocytosis. Conclusions: 1) We found a less frequent association between IBD and LE than was previously reported: according to strict histopathological criteria, 2% of adult patients with IBD had LE. This may be due to differences between pediatric and adult IBD. Alternatively, it may be methodological, because unlike previously we prospectively evaluated consecutive patients with IBD. 2) Peripapillary lymphocytosis was seen in 10% of patients with CD, and was associated with elevated inflammatory markers. These observations suggest PL may be a marker of inflammation. 3) Further evaluation is required to assess the relationships among LE, GERD, and IBD.