Esophagitis: old histologic concepts and new thoughts

Investigating the therapeutic effects and potential mechanisms of Zuojin Pill in the treatment of gastroesophageal reflux disease

ETHNOPHARMACOLOGICAL RELEVANCE

Zuojin Pill (ZJP), a traditional Chinese medicinal formula, is widely recognized for its diverse pharmacological properties in the management of gastrointestinal disorders. However, the precise mechanisms underlying its therapeutic effects in gastroesophageal reflux disease (GERD) remain inadequately understood.

AIM OF THE STUDY

This study aims to investigate the therapeutic effects of ZJP in GERD and to elucidate the molecular mechanisms involved.

MATERIALS AND METHODS

The chemical composition of ZJP was characterized using HPLC-Q-Exactive-MS. A rat model of GERD was established through esophagogastric anastomosis, and three different doses of ZJP were administered. Histological changes were assessed via hematoxylin-eosin (H&E) staining, while pro-inflammatory cytokines were quantified to evaluate the anti-inflammatory effects of ZJP. Network pharmacology combined with bioinformatics analysis was employed to predict potential therapeutic targets and signaling pathways of ZJP in GERD. Validation of the mechanisms was conducted through Western blotting, immunofluorescence (IF), transmission electron microscopy (TEM), and immunohistochemistry (IHC).

RESULTS

The results demonstrated that ZJP effectively alleviated pathological alterations and reduced pro-inflammatory cytokine levels in esophageal tissues of GERD rats. Western blotting and IF analysis of E-cadherin and claudin-1 confirmed that ZJP enhanced the integrity of the esophageal mucosal barrier. TEM imaging revealed that ZJP restored intercellular space (DIS), increased desmosome density, thereby protecting esophageal tissues from the detrimental effects of GERD. Furthermore, ZJP modulated macrophage polarization in the GERD rat model. Mechanistic investigations indicated that ZJP exerted its therapeutic effects by inhibiting MAPK/NF-κB signaling pathway activation and downregulating the expression of prostaglandin-endoperoxide synthase 2 (PTGS2) and matrix metalloproteinase 2 (MMP2), consistent with predictions from network pharmacology analysis.

CONCLUSIONS

This study provides comprehensive evidence for the therapeutic efficacy of ZJP in GERD, acting through modulation of inflammation, mucosal barrier integrity, and macrophage polarization. Additionally, ZJP downregulated PTGS2 and MMP2 expression and suppressed the activation of MAPK/NF-κB signaling pathways, underscoring its potential as a therapeutic intervention for GERD.

'Sneaky' uninflamed oesophageal candidiasis: morphological clues and comparison with candidiasis associated with inflammation

AIMS

Candida esophagitis is usually readily identified on routine H&E-stained sections as the infection typically presents with prominent acute inflammation as a clue to search for organisms. However, in some cases, inflammation is absent, and detection of organisms relies on the observation of zones exhibiting parakeratosis with a delicate 'flaky' appearance. Our study aimed to establish a correlation between the histomorphology of oesophageal candidiasis and an associated clinical profile.

METHODS

We reviewed 53 sequential biopsy specimens from patients with Candida esophagitis collected over 1 year. Biopsies were assessed for acute inflammation, intraepithelial lymphocytosis and lymphoid aggregates. Patients' medical records were reviewed for data on age, gender, race, immune status, smoking, corticosteroid use, HIV status and organ transplantation history. Correlations between these factors and histomorphological patterns were assessed using test.

RESULTS

Of the 53 biopsies, 20 lacked acute inflammation and 33 had it. 15 biopsies showed both acute and lymphoid inflammation and 5 showed lymphocytosis only. Among 16 smokers, 6 (37%) had acute inflammation and 10 (63%) had parakeratosis. In non-smokers, 24 (71%) had acute inflammation and 10 (29%) had parakeratosis. A significant correlation was found between smoking and absence of acute neutrophilic infiltration (p=0.025), but no other clinical factor was associated with inflammatory patterns.

CONCLUSIONS

Candida esophagitis can be uninflamed with 'flaky' parakeratosis or associated with acute inflammation or lymphocytosis with or without neutrophilic infiltration. Inflammation was often absent in smokers, suggesting synergistic local immunosuppressive effect is this overall immunosuppressed population.

Clinical and Histopathologic Features Can Help Target Immunohistochemical Stain Use in the Diagnosis of Viral Esophagitis

OBJECTIVES

Herpes simplex virus (HSV) and cytomegalovirus (CMV) immunohistochemical stains (IHC) are frequently applied on esophageal biopsies. Our aims were to identify IHC use patterns in viral esophagitis (VE), and clinicopathologic features of VE that could guide IHC use.

METHODS

We included 58 VE cases and 60 controls, defined as patients with negative HSV/CMV IHC between January 2006 and July 2017. Biopsies were reviewed and histologic features and clinical data recorded.

RESULTS

Thirteen cases required IHC for diagnosis. IHC was performed in 13 HSV and 5 CMV cases where diagnostic viral inclusions were present. VE patients were more likely to have endoscopic ulcer (P=0.002) and be immunocompromised (P<0.001). Pretest clinical concern for VE was common (P=0.006). Histologically, VE patients were more likely to have ulcer (P=0.004), ulcer exudate rich in neutrophils and histiocytes (P=0.001), neutrophils in squamous mucosa (P<0.001), histiocyte aggregates >15 (P<0.001) and spongiosis (P<0.001). Controls had frequent eosinophils, alone (P=0.008) or admixed with other inflammatory cells (P<0.0001).

CONCLUSIONS

IHC is used in VE biopsies despite definite viral inclusions on hematoxylin and eosin and in patients without concerning histology or clinical concern for VE. History, endoscopic findings, and histology can be used to better target IHC use in VE.

Normal gastrointestinal tract inflammatory cells and review of select benign hematolymphoid proliferations

The luminal gastrointestinal tract can be a site of robust immune response in which reactive lymphoproliferative processes can sometimes be difficult to distinguish from lymphoma. In this article, we review gastrointestinal tract normal resident inflammatory cells and common nonneoplastic lymphoproliferative responses with emphasis on their differential and links to lymphoma. Topics that are covered include lymphocytic esophagitis, gastric chronic inflammation, mucosa-associated lymphoid tissue, and ulceration, small intestinal lymphoid hyperplasia, celiac disease, microscopic colitis, inflammatory bowel disease, primary immunodeficiency, graft-versus-host disease, and anti-programmed cell death protein-1 effect. We additionally present the less common differential of histiocytic processes within the gastrointestinal tract. The aim of this paper is to serve as a reference for practicing pathologists facing lymphoid, lymphoplasmacytic, or histiocytic processes in the luminal gastrointestinal tract. We hope to help the practicing pathologist distinguish benign from malignant entities and identify features requiring further workup.

Novel and rare forms of oesophagitis

Our understanding of inflammatory diseases of the gastrointestinal tract, including those of the oesophagus, has expanded in recent years. Once attributed almost exclusively to gastro-oesophageal reflux disease or infection, it is now recognised that oesophagitis may occur due to a variety of distinct disease entities. Many of these conditions cause debilitating and persistent symptoms, impacting upon quality of life and necessitating ongoing surveillance and treatment. This review will consider the clinical, endoscopic and histopathological features of these novel and rare forms of oesophagitis.

A preliminary report on the use of Midodrine in treating refractory gastroesophageal disease: Randomized Double-Blind Controlled Trial

BACKGROUND

Gastroesophageal reflux disease (GERD) is a common disease with various clinical presentations. Acid suppression with proton pump inhibitors and lifestyle modification may not lead to satisfactory response in a substantial portion of patients. We investigated the possible effect of midodrine in patients with refractory GERD.

METHODS

Patients suffering from GERD and were refractory to one-month course of pantoprazole 40mg twice daily entered the study. This was a pilot, randomized, double-blind, and placebo-controlled study. After randomization, one group received Midodrine 5mg before meals for one month, and the other group received placebo for the same period. Meanwhile, pantoprazole was continued 40mg twice daily in both arms. The severity of symptoms was evaluated by the visual scoring system. Quality of life (QoL) in both groups was measured using a standardized version of Quality of Life in Reflux and Dyspepsia questionnaire (QOLRAD).

RESULTS

A total of twenty patients were enrolled in this study. There was a significant interaction between the groups and time on all measured scores based on QOLRAD questionnaire. All the markers in the Midodrine group had significant improvement over time, but the placebo group did not show any significant improvement. Both visual severity score and total QoL score in Midodrine arm showed a U shape change during  6 weeks.

CONCLUSIONS

Midodrine before a meal could be useful in alleviating symptoms and improving QoL in the patients with refractory gastroesophageal disease.

Educational Case: Infectious Esophagitis

The following fictional case is intended as a learning tool within the Pathology Competencies for Medical Education (PCME), a set of national standards for teaching pathology. These are divided into three basic competencies: Disease Mechanisms and Processes, Organ System Pathology, and Diagnostic Medicine and Therapeutic Pathology. For additional information, and a full list of learning objectives for all three competencies, seehttp://journals.sagepub.com/doi/10.1177/2374289517715040.¹

The microscopic anatomy of the esophagus including the individual layers, specialized tissues, and unique components and their responses to injury

The esophagus, a straight tube that connects the pharynx to the stomach, has the complex architecture common to the rest of the gastrointestinal tract with special differences that relate to its function as a conduit of ingested substances. For instance, it has submucosal glands that are unique and have a specific protective function. It has a squamous lining that exists nowhere else in the gut except the anus and it has a different submucosal nerve plexus when compared to the stomach and intestines. All of the layers of the esophageal wall and the specialized structures including blood and lymphatic vessels and nerves have specific responses to injury. The esophagus also has unique features such as patches of gastric mucosa called inlet patches at the very proximal part and it has a special sphincter mechanism at the most distal aspect. This review covers the normal microscopic anatomy of the esophagus and the patterns of reaction to stress and injury of each layer and each special structure.

Relevance of histology in the diagnosis of reflux esophagitis

Reflux esophagitis is an important clinical diagnosis; however, the histologic findings can be nonspecific and overlap with other entities. Various benign changes can produce diagnostic difficulties for pathologists. In this review, the typical histologic findings of gastroesophageal reflux disease (GERD) of the esophagus are discussed, along with the issues relating to clinical correlation and technical aspects of endoscopic biopsies and specimen processing. The literature has been reviewed to discuss histologic definitions of GERD as well as current and developing controversies in the area of GERD. Histologic features are not entirely sensitive or specific for GERD. Awareness of these problems is essential; clinical and endoscopic information can be very useful in distinguishing GERD from other inflammatory lesions.

Diagnostic approaches and treatment of eosinophilic esophagitis. A review article

Eosinophilic Esophagitis (EoE) is a condition that involves eosinophilic influx into the esophageal epithelium. It affects both children and adults; Adults present with dysphagia whereas children with vague abdominal complaints. The clinical symptoms as well as pathologic features of EoE and gastro esophageal reflux disease (GERD) are similar. Since eosinophilia in the esophagus is a non-specific finding, the clinical presentation in conjunction with endoscopic findings and pathology, is crucial in determining a differential diagnosis. Infections such as parasites, allergic phenomenon, Crohn's disease, malignancies, medication, and chemotherapy are all associated with eosinophilia.

A primary endoscopic difference to note between EoE and GERD is that EoE often involves long segments of the esophagus, could be patchy or focal and frequently involves the proximal esophagus. GERD, however, typically involves the distal much more frequently than the proximal esophagus. Because of the similarity between them, GERD should be excluded by using high dose proton pump inhibitor (PPI) treatment or through evidence of a normal pH by esophageal testing, prior to treatment with an elimination diet or steroids. Until further research establishes different diagnostic tests and criteria, clinical and pathological response to therapy is considered to be the absolute confirmation of this diagnosis. The following is a more detailed discussion of this entity.

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EoE is an eosinophilic influx into the esophagus epithelium.

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It is an allergic reaction of esophagus to food particles and allergens.

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Adults present with dysphagia and reflux-like symptoms whereas children with vague abdominal complaints.

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Clinical presentation, endoscopic findings and pathology determine the definitive diagnosis.

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Treatment starts with an elimination diet and followed by orally swallowed inhaled steroids.

Challenges to "Classic" Esophageal Candidiasis: Looks Are Usually Deceiving

Objectives

We undertook the first case control study of histologically confirmed esophageal candidiasis (EC).

Methods

A computer search from July 2012 through February 2015 identified 1,011 esophageal specimens, including 40 cases of EC and 20 controls.

Results

The EC incidence was 5.2%; it was associated with immunosuppression and endoscopic white plaques and breaks. Smoking was a predisposing factor, and alcohol was protective. EC had no unique symptoms, and 54% of endoscopic reports did not suspect EC. Important histologic clues included superficial and detached fragments of desquamated and hyper-pink parakeratosis, acute inflammation, intraepithelial lymphocytosis, dead keratinocytes, and bacterial overgrowth. Thirty percent had no neutrophilic infiltrate. Pseudohyphae were seen on H&E in 92.5% (n = 37/40). "Upfront" periodic acid-Schiff with diastase (PAS/D) on all esophageal specimens would have generated $68,333.49 in patient charges. Our targeted PAS/D strategy resulted in $13,044.87 in patient charges (cost saving = 80.9%, $55,288.62).

Conclusions

We describe the typical morphology of EC and recommend limiting PAS/D to cases where the organisms are not readily identifiable on H&E and with at least one of the following: (1) ulcer, (2) suspicious morphology, and/or (3) clinical impression of EC.

Fungal Esophagitis Presenting With Esophagitis Dissecans Superficialis: Cause or Concurrence? A Diagnostic Conundrum

Esophagitis dissecans superficialis (EDS) is a rare desquamative disorder of the esophagus. It is characterized by sheets of sloughed squamous tissue with normal underlying mucosa. We present a case of a 68-year-old man with severe anemia and a positive fecal occult blood test who was found to have features suggestive of EDS during endoscopy. However, histological features were suggestive of both EDS and fungal esophagitis. To our knowledge, this is the first reported case in literature which discusses the clinical scenario of fungal infection being a possible etiology rather than a commonly accepted differential diagnosis of EDS. We also review the clinical features, diagnostic criteria and treatment of EDS.

Lymphocytic oesophagitis, eosinophilic oesophagitis and compound lymphocytic-eosinophilic oesophagitis I: histological and immunohistochemical findings

AIMS

To report four histological-immunohistochemical oesophagitis phenotypes.

METHODS

Oesophageal biopsies from 311 patients were stained with H&E and with CD3, a T cell marker. Additional immunohistochemical stains (n=413) were performed in 77 cases.

RESULTS

Four histological-immunohistochemical oesophagitis phenotypes were recorded: lymphocytic oesophagitis (LyE, ≥40 CD3+ lymphocytes/HPF in CD3 immunostain), eosinophilic oesophagitis (EoE, ≥15 eosinophils/HPF in H&E stain), lymphocytic infiltration (≤39 CD3+/HPF) and compound lymphocytic oesophagitis-eosinophilic oesophagitis (Co LyE-EoE). At index biopsy, 28.3% (n=88) had LyE, 21.2% (n=66) EoE, 10.6% (n=33) Co LyE-EoE and 39.9% (n=124) lymphocytic infiltration. A persistent oesophagitis phenotype was found in 42.5% (37/87) in the first follow-up biopsy, in 34.4% (21/61) in the second follow-up biopsy and in 48.1% (26/54) in the third follow-up biopsy. Using βF1 immunostain, two different surface T cell receptors were detected in LyE and Co Lye-EoE: one having ≥40 βF1+/HPF (βF1+ high) and the other having <39 βF1+/HPF (βF1+ low).

CONCLUSIONS

Based on the literature regarding the significance of intraepithelial lymphocytes (IELs) in the initiation of EoE, we submit that the IEL phenotypes in LyE might differ from those found in EoE as they were unable to elicit the same eosinophilic response. Recent studies disclosed that group 2 innate lymphocytes (ILC2s), enriched in EoE, remain undetected in CD3 immunostain as they lack surface markers for T, B, natural killer (NK) or NK T cells. If ILC2s also participate in the lymphocytic infiltration of EoE, then the frequency of cases with Co LyE-EoE here reported might have been much higher. The four oesophagitis phenotypes described are easy to recognise, provided that the dual staining procedure (H&E-CD3) is implemented.