Esophageal Biopsies Of Patients Research Articles

Expression of inducible nitric oxide synthase, nitrotyrosine, eosinophilic peroxidase, eotaxin-3, and galectin-3 in patients with gastroesophageal reflux disease, eosinophilic esophagitis, and in healthy controls: a semiquantitative image analysis of 3,3'-diaminobenzidine-stained esophageal biopsies.

Eosinophilic esophagitis (EoE) and gastroesophageal reflux disease (GERD) share many histopathological features; therefore, markers for differentiation are of diagnostic interest and may add to the understanding of the underlying mechanisms. The nitrergic system is upregulated in GERD and probably also in EoE. Esophageal biopsies of patients with EoE (n = 20), GERD (n = 20), and healthy volunteers (HVs) (n = 15) were exposed to antibodies against inducible nitric oxide synthase (iNOS), nitrotyrosine, eosinophilic peroxidase, eotaxin-3, and galectin-3. The stained object glasses were randomized, digitized, and blindly analyzed regarding the expression of DAB (3,3'-diaminobenzidine) by a protocol developed in QuPath software. A statistically significant overexpression of iNOS was observed in patients with any of the two inflammatory diseases compared with that in HVs. Eotaxin-3 could differentiate HVs versus inflammatory states. Gastroesophageal reflux patients displayed the highest levels of nitrotyrosine. Neither iNOS nor nitrotyrosine alone were able to differentiate between the two diseases. For that purpose, eosinophil peroxidase was a better candidate, as the mean levels increased stepwise from HVs via GERD to EoE. iNOS and nitrotyrosine are significantly overexpressed in patients with EoE and GERD compared with healthy controls, but only eosinophil peroxidase could differentiate the two types of esophagitis. The implications of the finding of the highest levels of nitrotyrosine among gastroesophageal reflux patients are discussed.

Clinical value of random esophageal biopsies in patients with dysphagia and normal endoscopy who are treated with a proton pump inhibitor.

Rome IV recommended esophageal biopsies in patients with dysphagia and normal endoscopy to exclude mucosal disease. Thus far, studies evaluating the utility of this recommendation remain scarce. The aims of this study were to determine the value of random esophageal biopsies in heartburn patients with dysphagia and normal endoscopy and compare the yield of random esophageal biopsies between younger versus older patients. Data were collected from consecutive patients presenting with dysphagia, 18years and older, who were on proton pump inhibitors and had normal upper endoscopy. Biopsy results of patients with and without heartburn were recorded. Logistic regression analysis was used to compare normal versus abnormal biopsy results in younger and older patients accounting for confounding variables. The number of abnormal biopsies was significantly higher than normal biopsies (68% and 32%, respectively, P = 0.0001). Among abnormal biopsy results, microscopic gastroesophageal reflux disease was significantly more common than all other findings (39%, P = 0.0495). There was no significant difference in biopsy results in patients with and without heartburn as well as younger versus older patients (P = 0.3384, P = 0.1010, and P = 0.8468, respectively). Our study demonstrated that most patients with dysphagia and normal upper endoscopy who are on proton pump inhibitor have some type of histologic mucosal abnormality, which can direct future management. Among abnormal biopsies, microscopic reflux was by far the most common finding in patients with or without a history of heartburn. While this supports the management strategy proposed by Rome IV, age did not drive esophageal biopsy results.

Molecules involved in the development of Barrett's esophagus phenotype in chronic eosinophilic esophagitis.

This paper aims to investigate the molecules involved in development of Barrett's esophagus (BE) in human eosinophilic esophagitis (EoE). Histopathological, immunohistochemical, real-time PCR Immuno blot, and ELISA analyses are performed to identify the signature genes and proteins involved in the progression of BE in EoE. We detected characteristic features of BE like intermediate columnar-type epithelial cells, induced BE signature genes like ErbB3, CDX1, ErbB2IP in the esophageal mucosa of patients with EoE. In addition, we had observed several BE-associated proteins such as TFF3, p53 and the progression markers like EGFR, p16, MICA, MICB, and MHC molecules in esophageal biopsies of patients with chronic EoE. Interestingly, we also detected mucin-producing columnar cells and MUC-2, MUC-4, and MUC5AC genes and proteins along with induced IL-9 in patients with chronic EoE. A strong correlation of IL-9 with mucin genes is observed that implicated a possible role for IL-9 in the transformation of esophageal squamous epithelial cells to columnar epithelial cells in patients with EoE. These findings indicate that IL-9 may have an important role in BE development in patients with chronic EoE. We also discovered that IL-9 stimulates mucin-producing and barrier cell transcripts and proteins such CK8/18, GATA4, SOX9, TFF1, MUC5AC, and tight junction proteins in primary esophageal epithelial cells when exposed to IL-9. Taken together, these findings provide evidence that indeed IL-9 has a role in the initiation and progression of BE characteristics like development of mucin-producing columnar epithelial cells in patients with chronic EoE.NEW & NOTEWORTHY Intermediate columnar-type epithelial cells are observed in biopsies of patients with EoE. Induced BE signature genes (CK8/18, CDX1 GATA4, SOX9, and Occludin) were observed in patients with chronic EoE. Induction of IL-9 and its correlation with eosinophils mucin-producing genes and proteins was observed in patients with EoE. Induced IL-9 may be responsible for the development of BE in patients with chronic EoE.

Quantitative Analysis of Tug Sign: An Endoscopic Finding of Eosinophilic Esophagitis

Eosinophilic esophagitis (EoE) is a chronic immune-mediated disorder characterized by esophageal inflammation and dysfunction, with a rising incidence affecting approximately 1:1000 individuals worldwide.1,2 Chronic inflammation can lead to tissue remodeling in the esophagus with fibrosis in the lamina propria that is partially responsible for symptoms and complications of EoE.3,4 At times, a firmness to the esophagus can be appreciated with a noticeable force required to obtain biopsies from EoE. This sensation has been described as the "tug" or "pull" sign.5,6 Recently, with the advent of endoscopic functional luminal impedance, the fibroelastic properties of the esophagus, including diminished compliance and distensibility, have been described in patients with EoE.7 Quantification of these fibroelastic properties of the esophagus may aid in diagnosis and prognosis of EoE. To this date, a method to quantitatively measure the "tug sign" has not been developed. The primary objective of this study was to measure if a quantifiable difference in force is required to obtain endoscopic esophageal biopsies in patients with EoE compared with those without.

Evaluation of philagrin expression in esophageal biopsies of patients with eosinophilic esophagitis

Evaluation of philagrin expression in esophageal biopsies of patients with eosinophilic esophagitis

Clonally expanded, GPR15-expressing pathogenic effector TH2 cells are associated with eosinophilic esophagitis.

Eosinophilic esophagitis (EoE) is an allergic disorder characterized by the recruitment of eosinophils to the esophagus, resulting in chronic inflammation. We sought to understand the cellular populations present in tissue biopsies of patients with EoE and to determine how these populations are altered between active disease and remission. To this end, we analyzed cells obtained from esophageal biopsies, duodenal biopsies, and peripheral blood of patients with EoE diagnosed with active disease or remission with single-cell RNA and T cell receptor (TCR) sequencing. Pathogenic effector TH2 (peTH2) cells present in the esophageal biopsies of patients with active disease expressed distinct gene signatures associated with the synthesis of eicosanoids. The esophageal tissue-resident peTH2 population also exhibited clonal expansion, suggesting antigen-specific activation. Peripheral CRTH2+CD161- and CRTH2+CD161+ memory CD4+ T cells were enriched for either a conventional TH2 phenotype or a peTH2 phenotype, respectively. These cells also exhibited substantial clonal expansion and convergence of TCR sequences, suggesting that they are expanded in response to a defined set of antigens. The esophagus-homing receptor GPR15 was up-regulated by peripheral peTH2 clonotypes that were also detected in the esophagus. Finally, GPR15+ peTH2 cells were enriched among milk-reactive CD4+ T cells in patients with milk-triggered disease, suggesting that these cells are an expanded, food antigen-specific population with enhanced esophagus homing potential.

Utility of Routine Esophageal Biopsies in Patients With Refractory Reflux Symptoms.

This study aimed to assess the diagnostic yield of routine esophageal biopsies in patients with refractory reflux symptoms. We prospectively enrolled consecutive patients referred for upper endoscopy and collected histological, clinical, and endoscopic data. Of the 301 included patients, 14 (4.7%) patients met the clinicopathological diagnostic definition of eosinophilic esophagitis. Presence of dysphagia, food bolus impaction, atopic background, and typical endoscopic features were the factors with the strongest association and diagnostic accuracy for eosinophilic esophagitis. The diagnostic yield in patients lacking symptoms of dysphagia or endoscopic features was negligible (0% and 1.9%, respectively). Routine esophageal biopsy sampling in patients with refractory reflux symptoms has a low diagnostic yield. Esophageal biopsies should only be obtained in patients with refractory reflux symptoms who also present with dysphagia (see Visual abstract, Supplementary Digital Content 2, http://links.lww.com/AJG/B792).

Loss of Peptidyl‐Arginine Deiminase 1‐mediated Citrullination Drives Esophageal Epithelial Barrier Impairment in Allergic Inflammation

BackgroundCitrullination or deimination is a post‐translational modification in which neutral arginine residues are converted to positive citrulline by members of the peptidyl‐arginine deiminase (PADI) family. PADI1 is an esophageal enriched gene that is significantly downregulated in Eosinophilic Esophagitis (EoE), an eosinophilic‐driven chronic allergic inflammatory disorder characterized by reduced tissue differentiation and impaired esophageal epithelial barrier formation. While the role of PADI1 in deiminating structural proteins has been implicated in epithelial cell populations, including the skin, the functional significance and extent of PADI1‐mediated citrullination in allergic inflammation remains understudied.HypothesisHerein we hypothesize that the loss of PADI1‐mediated citrullination drives esophageal epithelial barrier impairment in allergic inflammation.MethodsPADI1 WT and KO EPC2 immortalized human esophageal epithelial cells generated by CRISPR‐Cas9 were grown in either monolayer or at Air‐Liquid Interface (ALI) to mimic esophageal differentiation. Transepithelial Electrical Resistance (TEER) measurements of EPC2 cells grown at ALI were measured as a function of barrier integrity. Transcriptional, protein and epigenetic analyses were conducted on EPC2 cells grown at ALI treated with or without IL‐13, a T‐cell derived cytokine known to induce responses involved in EoE. Immunofluorescence (IF) was used to visualize structural proteins and assess overall level of citrullination.ResultsPADI1 protein was found to be most highly expressed in the Esophageal Mucosa as compared to all other tissue types, specifically in the suprabasal layer of differentiated esophageal cells. PADI1 RNA expression was decreased eight‐fold (P < 0.0001) in esophageal biopsies of patients with EoE as compared to control patients. Treatment of EPC2 cells with IL‐13 (100 ng/ml) at confluence reduced PADI1 mRNA by three‐fold (P < 0.01). PADI1 KO cells demonstrate altered differentiation as assessed by decreased levels of citrullinated proteins and structural epithelial proteins, including filaggrin, involucrin, desmoglein‐1, E‐cadherin, and cornulin compared with wild‐type control cells.ConclusionOur data suggest that loss of PADI1‐mediated citrullination may drive esophageal epithelial barrier impairment in allergic inflammation.Support or Funding InformationThis work is supported by PHS Grant R01‐AI124355 and the Ohio Physiological Society.

400 Clinical Overlap Between Lymphocytic Esophagitis and Reflux Esophagitis With Increased Lymphocytic Infiltration

INTRODUCTION: Lymphocytic Esophagitis (LyE) is an increasingly recognized clinicopathologic entity with an emerging definition. A significant histologic and clinical overlap exists between LyE and reflux esophagitis (RE; however, no specific associations have been elucidated. Previous studies have shown that absence or decrease in the number of granulocytes in esophageal biopsies in patients with LyE have correlated with a different phenotypic presentation from reflux esophagitis, with more patients being predominantly older women with dysphagia. The aim of this study was to help differentiate the two entities based on their clinical characteristics. METHODS: A retrospective chart review was performed of all patients with a biopsy diagnosis of LyE between 2009-2018 at a large tertiary academic institution. Biopsies were then re-categorized into two groups: LyE with few granulocytes (LyE-FG), and reflux esophagitis with increased IELs (RE-IEL). Data regarding socio-epidemiologic, clinical, and histologic findings were collected. RESULTS: A total of 53 biopsies were reviewed (35 RE-IEL, 18 LyE-FG). Most patients were Caucasian- 78% and 75% in RE-IEL and LyE-FG groups, respectively (P = 0.559). Baseline characteristics were similar between the two groups (Table 1). Dysphagia was the most common symptom in both groups with 70.4% in RE-IEL and 75% in LyE-FG groups (P = 0.767) with heartburn being the second most common symptom (63% vs 60%; P = 0.850) respectively. More patients in the LyE-GF group had inflammatory bowel disease (17.6% vs 6.7%); however, this difference was not statistically significant (P = 0.241). A significant number of patients were on proton pump inhibitor (PPI) at the time of diagnosis (75.9% RE-IEL vs 80% LyE-IG; P = 0.756). Patients with RE-IEL were more often smokers (63.3% vs 40%); however, there was no statistical significance (P = 0.138). There was no statistical significance between rates of NSAID or alcohol use between the two groups. Site of biopsy was not statistically significant between the two groups (P = 0.306) with the majority of biopsies taken from the distal esophagus. CONCLUSION: Our study shows the clinical overlap between LyE-FG and RE-IEL. RE and LyE share significant histologic overlap; however, LyE is clinically characterized by dysphagia as the most predominant symptom compared to classic RE, where heartburn and regurgitation are more common.

An Evaluation of the Quality of Esophageal Biopsies in Patients with Eosinophilic Esophagitis

Introduction: Eosinophilic esophagitis (EoE) is a clinicopathologic diagnosis based on the presence of ≥15 eosinophils per high power field (hpf) in the epithelium. Additional changes include microabscesses, lamina propria (LP) papillae elongation, basal zone hyperplasia, intercellular edema, and LP fibrosis. Recent studies have shown the importance of subepithelial fibrosis as this correlates with clinical and endoscopic findings of EoE, disease duration and response to therapy. We sought to determine the adequacy of esophageal biopsies, defined as the presence of LP, among patients with EoE. Methods: This was a single-center, retrospective, observational study at a tertiary referral center. The pathology database was interrogated to identify pathology records from 2014-2015 that contained ≥15 eosinophils/hpf. All records were reviewed by one expert GI pathologist for the presence of lamina propria. We investigated factors that could influence acquisition of deeper esophageal biopsies including type of sedation, trainee involvement, procedure duration and seniority of attending endoscopist. Results: We reviewed 119 pathology records that were contributed by 109 patients. Within the pathology records, 244 esophageal biopsies were reviewed and classified by location (proximal, distal, and other; note that a pathology record could contribute multiple location biopsies). Only 98 biopsies had the presence of LP (40%). Breakdown according to location: proximal biopsies 25/66 (38%); distal biopsies 34/90 (38%); and other biopsies 39/88 (44%) had the presence of LP. Univariable generalized linear mixed models were used to estimate the odds of a higher number of LP biopsies. Patient demographics, trainee involvement, seniority of attending endoscopist, sedation used, and procedure time were not associated with odds of a higher number of LP biopsies. When analyzed by location of biopsies, senior attending physicians (defined as > 3 years in practice) were 3.74 (95% CI: 1.45 - 9.65) times as likely to obtain a positive distal biopsy with LP when compared to junior attendings (p = 0.01). Conclusion: The majority of biopsies did not contain LP. Senior attendings were more likely to obtain quality distal biopsies. Duration of procedure, sedation type, and trainee involvement did not affect depth of biopsy. As esophageal biopsy remains the gold standard for monitoring disease activity, quality of mucosal sampling is essential to providing accurate information to guide clinical management.395_A Figure 1. Odds of a higher count of lamina propria biopsies395_B Figure 2. Odds of a positive LP on distal biopsy

Esophageal Biopsies for All? The Diagnostic Yield of Esophageal Biopsies in Patients Referred for EGD to Investigate Dysphagia in Excluding Significant Esophageal Eosinophilia When No Other Cause Is Apparent

Esophageal Biopsies for All? The Diagnostic Yield of Esophageal Biopsies in Patients Referred for EGD to Investigate Dysphagia in Excluding Significant Esophageal Eosinophilia When No Other Cause Is Apparent

A standardized method for measuring intercellular spaces in esophageal biopsies in patients with suspected gastroesophageal reflux disease (the intercellular space ratio)

Objective. Dilated intercellular space (DIS) in esophageal biopsies is regarded as a possible early sign of mucosal injury in gastroesophageal reflux disease (GERD). This study presents a standardized approach of intercellular space measurement. Material and methods. Distal and proximal esophageal biopsies were taken from 19 patients with suspected GERD, and examined with TEM. A grid containing 150 line-crossing points was applied upon each photomicrograph. The number of points falling on the intercellular space was divided by the total number of points of the grid, thereby creating a ratio called the intercellular space ratio (ISR). The ISR method was validated with regard to intra- and interobserver agreement, and was compared to a widely used method for measuring intercellular space diameter developed by Tobey et al. (Tobey NA, Carson JL, Alkiek RA, Orlando RC. Dilated intercellular spaces: a morphological feature of acid reflux–damaged human esophageal epithelium. Gastroenterology 1996;111(5):1200–1205). The ISR was also compared to other markers for GERD. Results. Pearson's correlation coefficients for intra- and interobserver agreement were 0.91 (p < 0.001) and 0.82 (p < 0.001), respectively. The Pearson's correlation coefficient between the ISR and the intercellular space diameter according to Tobey et al., measured in the same micrographs, was 0.32 (p < 0.001). The proximal ISR correlated significantly with the distal ISR (Spearman's rho = 0.57, p = 0.010), and with heartburn symptom score (Spearman's rho = 0.50, p = 0.028). Conclusions. The ISR showed a high intraobserver and interobserver agreement. It also displayed good external validity when compared to other markers for gastroesophageal reflux. A rather poor correlation was however found between the ISR and the intercellular space diameter measured as described by Tobey et al.

Markers of Antigen Presentation and Activation on Eosinophils and T Cells in the Esophageal Tissue of Patients With Eosinophilic Esophagitis

Evidence suggests eosinophils may be acting as antigen-presenting cells (APCs) by presenting antigen to T cells. We investigated the surface proteins of eosinophils and T cells in the esophageal biopsies of patients with eosinophilic esophagitis (EoE), patients with gastroesophageal reflux disease (GERD), and healthy controls (HCs). : Subjects were categorized as EoE, GERD, or HC. In esophageal tissue, EG2+ eosinophils were stained for the APC markers, CD40 or CD80, via immunohistochemistry. CD3+ T cells were stained for costimulatory markers, CD40L or CD28, and for activation markers, CD69 or CD134, via immunofluorescence or immunohistochemistry. Eosinophils stained with CD40 and CD80. The number of EG2+CD40+ cells was increased in EoE (mean 19.1±14.8 cells/high-power field [HPF], n=11), compared with GERD (mean 0.13±0.19 cells/HPF, n=5, P<0.01) and HC (mean 0.3±0.7 cells/HPF, n=5, P<0.01). There was an elevation in EG2+CD80+ cells in EoE (mean 18.1±16.2 cells/HPF, n=10), GERD (mean 1.7±2.8 cells/HPF, n=6, P<0.01), or HC (mean 0.8±1.3 cells/HPF, n=6, P<0.01). CD3+ T cells stained with CD40L (not quantified). CD3+ T cells stained with CD28 at elevated levels in EoE (mean 14±8.7 cells/HPF, n=9) versus GERD (mean 3.3±1.2 cells/HPF, n=6, P<0.05) or HC (mean 3.0±3.2 cells/HPF, n=7, P<0.01). The number of CD3+CD69+ cells was highest in EoE (mean 14.8±7.5 cells/HPF, n=6) versus GERD (mean 0.8±0.9 cells/HPF, n=6, P<0.001) or HC (mean 2.7±2.5 cells/HPF, n=6, P<0.001). We show that esophageal eosinophils express CD40 and CD80, and T cells with CD40L, CD28, and CD69. The number of double-stained cells was higher in EoE in comparison to control groups. These data support the hypothesis that eosinophils in EoE may act as APCs, activating T cells.

Immunohistochemistry (IHC) Tests Panel on Esophageal Biopsies in Patients with Barrettʼs Esophagus: Does it Really Help?

Purpose: We have increasingly noted the use of immunohistochemistry testing (IHC) performed by outside pathology laboratories in patients subsequently referred for endoscopic therapy of Barrett's disease. While histology results are considered the gold standard in the diagnosis of esophageal dysplasia or adenocarcinoma (EAC), some centers now perform IHC testing regardless of histology findings. IHC panels purportedly confirm the presence of Barrett's esophagus (BE) and its malignant potential. IHC panels are reported as a composite of markers, such as MOC 31, BER-EP-4, AK1/AE3, CK 5/6/45/138/903, Villin, CDX2, and P16/21/53. The aim of our study is to correlate IHC results with esophageal biopsy histologic findings. Methods: We reviewed our prospectively collected BE treatment database for patients who underwent EMR (endomucosal resection) or ablation therapy using RFA (radiofrequency ablation) for BE lesions from 2002-2011. As IHC testing is not performed at our institution, we searched outside records of referred patients who had IHC tests performed elsewhere. Patients' demographics, outside esophageal biopsy pathology results, IHC results and our EMR or mucosal biopsy histology results were recorded. Results: We reviewed 456 patients' charts that underwent EMR or RFA for BE. Among them, we found 8 patients (50% Male) with BE who received IHC testing. Their mean age was 54.8 (range 35-71) years and mean BMI was 29.9 (range 27.6-35.4) kg/m2. EMR for nodular or dysplastic BE was performed in 3 patients while 5 had RFA. The agreement of histologic findings and IHC results was found in 4 patients with non-dysplastic BE. In the other 3 patients, while IHC testing found no Barrett's dysplasia, the mucosal biopsies found BE-HGD (high grade dysplasia) and subsequent EMR procedures found intramucosal and submucosal adenocarcinoma (1 each). In each of these 8 patients, IHC tests were performed on approximately 1-9 esophageal biopsy specimens adding cost of $108-$972 ($108 per biopsy specimen). Conclusion: In this small group of BE patients referred for endoscopic therapy, the results of IHC tests did not reliably detect BE dysplasia or cancer, compared with histologic analysis of mucosal biopsy or endoscopic resection specimens. The use of IHC tests added expense and provided unreliable BE disease stage information in our patients with esophageal cancer.

Su1150 Leukotriene C4 Synthase mRNA Levels are Upregulated in Esophageal Biopsies of Patients With Eosinophilic Esophagitis

Su1150 Leukotriene C4 Synthase mRNA Levels are Upregulated in Esophageal Biopsies of Patients With Eosinophilic Esophagitis

Endoscopic findings in patients with Schatzki rings: Evidence for an association with eosinophilic esophagitis

To investigate endoscopic findings in patients with Schatzki rings (SRs) with a focus on evidence for eosinophilic esophagitis (EoE). We consecutively approached all adult patients scheduled for elective outpatient upper endoscopy for a variety of indications at the German Diagnostic Clinic, Wiesbaden, Germany between July 2007 and July 2010. All patients with endoscopically diagnosed SRs, defined as thin, symmetrical, mucosal structures located at the esophagogastric junction, were prospectively registered. Additional endoscopic findings, clinical information and histopathological findings with a focus on esophageal eosinophilia (≥ 20 eosinophils/high power field) were recorded. The criteria for active EoE were defined as: (1) eosinophilic tissue infiltration ≥ 20 eosinophils/hpf; (2) symptoms of esophageal dysfunction; and (3) exclusion of other causes of esophageal eosinophilia. Gastroesophageal reflux disease was excluded by proton pump inhibitor treatment prior to endoscopy. The presence of ≥ 20 eosinophils/hpf in esophageal biopsies in patients that did not fulfil the criteria of EoE was defined as esophageal hypereosinophilia. A SR was diagnosed in 171 (3.3%; 128 males, 43 females, mean age 66 ± 12.9 years) of the 5163 patients that underwent upper gastrointestinal-endoscopy. Twenty of the 116 patients (17%) from whom esophageal biopsies were obtained showed histological hypereosinophilia (≥ 20 eosinophils/hpf). Nine of these patients (8 males, 1 female, mean age 49 ± 10 years) did not fulfill all diagnostic criteria of EoE, whereas in 11 (9%) patients with ≥ 20 eosinophils/hpf, a definite diagnosis of EoE was made. Three of the 11 patients (27%) with definite EoE had no suspicious endoscopic features of EoE. In contrast, in the 25 patients in whom EoE was suspected by endoscopic features, EoE was only confirmed in 7 (28%) patients. Patients with EoE were younger (mean age 41.5 ± 6.5 vs 50.5 ± 11.5 years, P = 0.012), were more likely to have a history of allergies (73% vs 29%, P = 0.007) and complained more often of dysphagia (91% vs 34%, P = 0.004) and food impaction (36% vs 6%, P = 0.007) than patients without EoE. Endoscopically, additional webs were found significantly more often in patients with EoE than in patients without EoE (36% vs 11%, P = 0.04). Furthermore, the SR had a tendency to be narrower in patients with EoE than in those without EoE (36% vs 18%, P = 0.22). The percentage of males (73% vs 72%, P = 1.0) and frequency of heartburn (27% vs 27%, P = 1.0) were not significantly different in both groups. The 9 patients with esophageal hypereosinophilia that did not fulfil the diagnostic criteria of EoE were younger (mean age 49 ± 10 years vs 58 ± 6 years, P = 0.0008) and were more likely to have a history of allergies (78% vs 24%, P = 0.003) than patients with < 20 eosinophils/hpf. Predictors of EoE were younger age, presence of dysphagia or food impaction and a history of allergies. A significant proportion of patients with SRs also have EoE, which may not always be suspected according to other endoscopic features.

Esophageal remodeling in pediatric eosinophilic esophagitis

Eosinophils are associated with airway remodeling in asthma, but studies have not yet determined whether eosinophilic esophagitis (EE) is associated with esophageal remodeling. We performed quantitative immunohistochemical analysis of remodeling changes in esophageal biopsy specimens from children with and without EE to evaluate if there were changes in the esophagus of pediatric patients with EE akin to airway remodeling. In addition, we determined whether the esophagus of patients with EE had increased levels of expression of TGF-beta(1) and its signaling molecule, phosphorylated SMAD2/3 (phospho-SMAD2/3). To determine esophageal levels of eosinophilic inflammation, fibrosis, and vascular activation, endoscopically obtained esophageal biopsy specimens from 7 patients with EE (5 strictured, 2 nonstrictured), 7 with gastroesophageal reflux disease, and 7 normal patients were processed for immunohistology, trichrome staining, and assessment of levels of expression of TGF-beta(1), phospho-SMAD2/3, and vascular cell adhesion molecule 1. Esophageal biopsies in patients with EE demonstrated increased levels of subepithelial fibrosis and increased expression of TGF-beta(1) and its signaling molecule phospho-SMAD2/3 compared with gastroesophageal reflux disease and normal control patients. In addition, esophageal biopsies in patients with EE demonstrated an increased vascular density and an increased expression of the vascular endothelial adhesion molecule, vascular cell adhesion molecule 1. Previously unrecognized esophageal remodeling changes analogous to aspects of airway remodeling are detectable in the subepithelial region of the esophagus in pediatric patients with EE. Pediatric patients with EE demonstrate increased fibrosis, vascularity, and vascular activation in the esophagus that may contribute to stricture formation and potentially provide a basis for stratifying patients with EE on the basis of disease severity and/or prognosis.

Detection of oxidative DNA damage (ODD) in esophageal biopsies of patients with reflux symptoms and normal pH monitoring studies

Detection of oxidative DNA damage (ODD) in esophageal biopsies of patients with reflux symptoms and normal pH monitoring studies

Dilated Intercellular Spaces as Markers of Reflux Disease: Histology, Semiquantitative Score and Morphometry upon Light Microscopy

Background and Aims: A recent electron microscopy study suggested that dilated intercellular spaces (DIS) are specific for acid reflux-damaged esophageal epithelium. Electron microscopy is, however, expensive and difficult to apply to routine biopsies. The aims of this study are to establish a method for assessing DIS on light microscopy of esophageal biopsies and to estimate its association with current clinicopathological parameters of esophagitis. Materials and Methods: 21 patients with reflux symptoms were investigated. Light microscopy biopsies were assessed for DIS size by a semiquantitative method and computer-assisted, static morphometry. A DIS score accounting for DIS size and distribution was assigned to each patient and its association with 30 clinicopathological variables investigated by univariate and multivariate logistic regression. Results: Both the semiquantitative method and static morphometry identified 4 different classes of DIS size. The DIS score was significantly and independently associated with the esophageal symptoms score, the histological score of esophagitis and the relevant morphometry data. Conclusions: DIS may be efficiently assessed during light microscopy of routine esophageal biopsies. Since correlation with both the histology and the symptoms of esophagitis, the DIS score may be considered a novel parameter of esophagitis and is suggested for the routine evaluation of esophageal biopsies in patients with reflux disease.

Acid suppression therapy in Barrett's esophagus: the importance of pH monitoring.

It is generally accepted that intestinal metaplasia of the esophageal mucosa results from chronic injuries caused by acid gastroesophageal reflux (GER). It would seem to follow, therefore, that appropriate therapy of Barrett’s esophagus, once recognized, should attempt to eliminate any continuing esophageal acid exposure. Indeed, the usual standard of care in this disease includes the use of potent acid-suppressing medications (or surgery) in an attempt to accomplish this goal. Such therapies have been well documented to result in resolution of the patient’s reflux symptoms and healing of associated esophagitis. There is, however, no present evidence that either of these therapeutic approaches results in regression of the metaplastic epithelium or elimination of the malignant potential in this disease. The observation that patients with Barrett’s esophagus have a decreased sensitivity to esophageal acid exposure indicates that control of heartburn in these patients does not ensure the absence of continuing acid reflux [1]. This possibility was initially documented by the study from our laboratory using ambulatory intra-esophageal pH monitoring, which showed that Barrett’s patients rendered asymptomatic on omeprazole frequently were having continued abnormal GER [2]. Subsequently, this phenomenon was better clarified by the observation that recovery of gastric acidity overnight, so-called “nocturnal acid breakthrough” occurs with high frequency even with twice-daily dosing of omeprazole [3]. These observations form the basis for the suggestion that long-term control of GER in patients with Barrett’s esophagus requires monitoring of intragastric and distal esophageal pH during the time when the patient is undergoing therapy. This concept has gained acceptance by many clinical investigators in this field. Does continuing acid reflux, even in diminished amount, constitute a threat to the patient with Barrett’s esophagus? The first suggestion that this might be true was provided by cell culture studies from esophageal biopsies of patients with Barrett’s esophagus showing that in vitro exposure to pulses of acid resulted in greater proliferation and less differentiation of the metaplastic epithelium [4]. A subsequent study by the same investigators provided the clinical link to the in vitro experiments. Using ambulatory pH monitoring during therapy with proton pump inhibitors (PPI) to establish the presence or absence of control of GER, these investigators documented that patients with continuing abnormal GER showed greater evidence of proliferation activity and less differentiation from their endoscopic biopsies than did patients with well-controlled GER [5]. Thus, experimental evidence both at the basic and clinical level supports the need for ambulatory pH monitoring to establish adequacy of acid suppression therapy and to guide titration of medication dosing in these patients. Does dose adjustment based on pH monitoring result in evidence of regression of the abnormal metaplastic epithelium in Barrett’s esophagus patients? Two recent clinical observations suggest an affirmative answer to this question. Our approach to patients with Barrett’s esophagus has been to use pH monitoring to adjust