Practical Teaching Cases

An 87-Year-Old Woman With Recurrent Dysphagia

Publish date: March 1, 2017
By
Roald F. Havre, MD, PhD
Trine Hallager
Adam S. Cheifetz, MD

Previously Published in Gastroenterology (2016;151:1085-6)

An 87-year-old woman was referred due to dysphagia that had been present for several years. Three years prior to this presentation she had undergone an esophagogastroduodenoscopy (EGD) on the same indication showing a proximal and a distal esophageal benign-appearing stricture but no signs of esophagitis. Both were dilated and biopsied. Histopathology showed infiltration with lymphocytes and neutrophilic granulocytes, and superficially fungal hyphae and spores. No predominance of eosinophilic granulocytes was noted. A proton-pump inhibitor was prescribed and she was scheduled for a control gastroscopy, but was lost to follow-up. She was otherwise healthy without any allergies.

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Upon re-presentation, she was under treatment with pantoprazole 40 mg OD. Upon EGD a spiral-shaped proximal esophageal stricture with normal-appearing mucosa only passable with a nasal endoscope was observed. The rest of the esophagus was seen with mucosal concentric rings (Figure A; video). The esophageal mucosa was otherwise endoscopically normal throughout. Biopsies were taken from the distal and proximal esophagus. Balloon dilation of the proximal stricture was performed (CRE, Boston Scientific) to 13.5 mm (video). Subsequently, a standard gastroscope could be passed to the duodenum revealing normal-appearing gastric and duodenal mucosa.

Dr. Havre and Dr. Kalaitzakis are in the Endoscopy Unit of Copenhagen University Hospital/Herlev, University of Copenhagen. Ms. Hallager is in the department of pathology, Copenhagen University Hospital/Herlev. The authors disclose no conflicts.

What is the diagnosis?

Eosinophilic esophagitis

Reflux associated esophagitis with stenosis

Lymphocytic esophagitis

Achalasia

The correct answer is C: lymphocytic esophagitis.

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Figure B

Histopathology showed well-differentiated squamous epithelium with dense intraepithelial lymphocytic infiltration of the peripapillary fields without neutrophilic or eosinophilic granulocytes. Focally there were areas with peripapillary intercellular edema/spongiosis (Figure B). There were CD3+/CD4+/CD8+ lymphocytes, without clear predominance of CD4+ or CD8+ lymphocytes (Figures C and D). Upon re-evaluation of the esophageal biopsies from the index endoscopy, neutrophilic granulocytes were reclassified as lymphocytes with shape alterations. Histopathology was diagnostic of LyE on both occasions.

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Figure C

The histologic findings of LyE were described in 20061 as abundant intraepithelial lymphocytes in the peripapillary fields of esophageal squamous mucosa with only rare neutrophils and/or eosinophils present. There are reports on associations with reflux, hypothyroidism, Crohn’s disease, allergies, and asthma1,2 but published reports are not unanimous.2,3 The etiology of LyE remains unknown. There is a wide age distribution and no clear gender predominance. The course of LyE is considered to be chronic but benign.2 Endoscopic findings suggestive of eosinophilic esophagitis, such as rings, are observed in 33.6% of LyE patients.3 Presenting symptoms are most often dysphagia or related to reflux. Treatment is symptomatic with PPI or balloon dilatation of strictures.

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Figure D

The patient’s dysphagia had improved 3 months following balloon dilation. She declined further follow-up.


References

1. Rubio, C.A., Sjodahl, K., Lagergren, J. Lymphocytic esophagitis: A histologic subset of chronic esophagitis. Am J Clin Pathol. 2006;125:432-7.

2. Cohen, S., Saxena, A., Waljee, A.K., et al. Lymphocytic esophagitis: A diagnosis of increasing frequency. J Clin Gastroenterol. 2012;46:828-32.

3. Haque, S., Genta, R.M. Lymphocytic oesophagitis: Clinicopathological aspects of an emerging condition. Gut. 2012;61:1108-14.

This article has an accompanying continuing medical education activity, also eligible for MOC credit (see Gastroenterology website for details). Learning Objective: Upon completion of this teaching case and questions, the learners will be able to identify one typical clinical and endoscopic presentation of the entity lymphocytic esophagitis, distinguish its histological pattern from other esophageal disorders and recognize a variety of other clinical presentations of this condition.

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