Esofagitis disecante superficial: entidad subdiagnosticada en pacientes pluripatológicos

Paciente de 76 años con múltiples comorbilidades presenta sintomatología gastrointestinal, donde la endoscopía digestiva alta revela mucosa esofágica "acartonada" en tercio distal, que a la toma de biopsia se produce esfacelación de 20 mm de largo por 6 mm de ancho, con sangrado que se autolimita. Muestra patológica es compatible con Esofagitis Disecante Superficial (EDS). Esta es una entidad poco frecuente descrita por primera vez en 1800, caracterizada endoscópicamente por desprendimiento de mucosa en tiras verticales como "cinta de papel de regalo", que se confirma mediante patología con una mucosa "bitonal", compuesta por una capa superficial eosinofílica y una zona basofílica de apariencia normal. Puede estar acompañada de inflamación mínima focal. La etiopatogenia no es clara; sin embargo, tiene buena respuesta a inhibidores de bomba de protones (IBPs). En nuestro caso la paciente presentaba todas las características de EDS, y ante su baja frecuencia reportada, se realizó revisión de literatura y discusión de esta rara entidad.

A 76-year-old patient presents multiple comorbidities and gastrointestinal symptoms. The upper gastrointestinal endoscopy exam reveals distal stiffness esophageal mucosa. A biopsy was taking creating sloughing of 20 mm long by 6 mm wide with self-limited bleeding. Specimen is compatible with Esophagitis Dissecans Superficialis (EDS). This is a rare entity first described in 1800, characterized endoscopically by mucosal detachment in vertical strips like "gift paper tape", which is confirmed by pathology with a mucosa with "two tones", composed of a eosinophilic superficial layer and a normal-appearing basophilic area. It may be accompanied by minimal focal inflammation. The etiopathogenesis is not clear; however, it has a good response to proton pump inhibitors (PPIs). In our case, the patient presented all the characteristics of EDS, and given its low reported frequency, a review of the literature and discussion of this rare entity was performed.

Avaliação da expressão da filagrina em biópsias esofágicas de pacientes com esofagite eosinofílica / Evaluation of philagrin expression in esophageal biopsies of patients with eosinophilic esophagitis

Introdução: Mutações do gene da filagrina vêm sendo associadas, classicamente, a alterações da barreira epitelial em doenças alérgicas com comprometimento da pele e das superfícies mucosas. Particularmente na dermatite atópica, a relação entre filagrina, mecanismo fisiopatológico e evolução clínica tem sido demonstrada. Recentemente, alterações da barreira epitelial com redução da expressão da filagrina, também têm sido associadas a mecanismos imunológicos envolvidos na patogênese da esofagite eosinofílica. Devido a disfunções na barreira epitelial, microrganismos e alérgenos são capazes de penetrarem no epitélio da mucosa esofágica, assim como na dermatite atópica. Objetivo: Avaliar a possível correlação da expressão da filagrina com os achados histopatológicos em biópsias esofágicas de pacientes com esofagite eosinofílica. Métodos: A expressão da filagrina foi investigada in situ, por imuno-histoquímica, em biópsias esofágicas nos seguintes grupos: Grupo I, controle (n=8), amostras provenientes de pacientes saudáveis; Grupo II (n=27), amostras provenientes de pacientes com esofagite eosinofílica. Resultados: Os resultados demonstraram uma diminuição da expressão da filagrina na mucosa do esôfago de portadores de esofagite eosinofílica. Adicionalmente, a intensidade da marcação imuno-histoquímica foi menor na mucosa esofágica com maior infiltração de eosinófilos. Conclusão: A diminuição da expressão de filagrina pode ser um fenomeno fisiopatológico associado ao aumento da quantidade de eosinófilos na mucosa esofágica, podendo impactar na evolução clínica da esofagite eosinofílica.

Introduction:Filaggrin gene mutations have been classically associated with changes in the epithelial barrier in allergic diseases involving the skin and mucosal surfaces. Particularly in atopic dermatitis, the relationship between filaggrin, pathophysiological mechanism and clinical evolution hás been demonstrated. Recently, changes in the epithelial barrier with reduced expression of filaggrin have also been associated with immunological mechanisms involved in the pathogenesis of eosinophilic esophagitis. Due to dysfunction in the epithelial barrier, microorganisms and allergens are able to penetrate the epithelium of the esophageal mucosa, as well as in atopic dermatitis. Objective: To evaluated the possible correlation of filaggrin expression with histopathological findings in esophageal biopsies of patients with eosinophilic esophagitis. Methods: Filaggrin expression was investigated in situ by immunohistochemistry in esophageal biopsies in the following groups: Group I, control (n = 8), samples from healthy patients; Group II (n = 27), samples from patients with eosinophilic esophagitis. Results: The results demonstrated a decrease in the expression of filaggrin in the esophageal mucosa of patients with eosinophilic esophagitis. Additionally, the intensity of the immunohistochemical labeling was lower in the esophageal mucosa with greater infiltration of eosinophils. Conclusion: The reduction of filaggrin expression may be a pathophysiological phenomenon associated with an increase in the quantity of eosinophils in the esophageal mucosa, which may impact on the clinical evolution of eosinophilic esophagitis.

Risk of preneoplastic lesions in mucosal projections of different sizes of the columnar epithelium in the lower esophagus / Risco de lesões pré-neoplásicas em projeções de mucosa de diferentes tamanhos do epitélio colunar no esôfago inferior

ABSTRACT BACKGROUND: Barrett's esophagus is an acquired condition that predisposes to the development of esophageal adenocarcinoma. AIMS: The aim of this study was to establish an association between the endoscopic and the histopathological findings regarding differently sized endoscopic columnar epithelial mucosa projections in the low esophagus, under 3.0 cm in the longitudinal extent. METHODS: This is a prospective study, including 1262 patients who were submitted to upper gastrointestinal endoscopy in the period from July 2015 to June 2017. The suspicious projections were measured and subdivided into three groups according to the sizes encountered (Group I: <0.99 cm; Group II: 1.0-1.99 cm; and Group III: 2.0-2.99 cm), and biopsies were then performed. RESULTS: There was a general prevalence of suspicious lesions of 6.42% and of confirmed Barrett's lesions of 1.17%, without a general significant statistical difference among groups. However, from Groups I and II to Group III, the differences were significant, showing that the greater the lesion, the higher the probability of Barrett's esophagus diagnosis. The absolute number of Barrett's lesions was 7, 9, and 6 for Groups I, II, and III, respectively. CONCLUSIONS: The findings led to the conclusion that even projections under 3.0 cm present a similar possibility of evolution to Barrett's esophagus. If, on the one hand, short segments are more prevalent, on the other hand, the long segments have the higher probability of Barrett's esophagus diagnosis, which is why biopsies are required in all suspicious segments.

RESUMO RACIONAL: O esôfago de Barrett é uma condição adquirida que predispõe ao desenvolvimento de adenocarcinoma de esôfago. OBJETIVOS: Estabelecer uma associação entre os achados endoscópicos e histopatológicos em relação às projeções endoscópicas da mucosa epitelial colunar de diferentes tamanhos no esôfago, abaixo de 3,0 centímetros de extensão longitudinal. MÉTODOS: Foi realizado um estudo prospective incluindo 1262 pacientes submetidos à endoscopia digestiva alta, no período de julho de 2015 a junho de 2017. As projeções suspeitas foram medidas, subdivididas em 3 grupos de acordo com os tamanhos encontrados (Grupo I: <0,99 cm; Grupo II: 1,0 cm-1,99 cm; Grupo III: 2,0 cm-2,99 cm) e biópsias foram então realizadas. RESULTADOS: Houve prevalência geral de lesões suspeitas de 6,42% e de lesões de Barrett confirmadas de 1,17%, sem diferença estatística geral significativa entre os grupos. Porém, dos Grupos I e II, para o Grupo III, as diferenças foram significativas, mostrando que quanto maior a lesão, maior a probabilidade de diagnóstico de esôfago de Barrett. O número absoluto de lesões de Barrett foi 7, 9 e 6 para os grupos I, II e III, respectivamente. CONCLUSÕES: Os achados permitiram concluir que mesmo projeções abaixo de 3,0 cm apresentam possibilidade semelhante de evolução para o esôfago de Barrett. Se, por um lado os segmentos curtos são mais prevalentes, por outro os segmentos longos têm maior probabilidade de diagnóstico de esôfago de Barrett, razão pela qual são necessárias biópsias em todos os segmentos suspeitos.

Dermatomyositis with exfoliation of esophageal mucosa: A case report / 中南大学学报(医学版)

Dermatomyositis (DM) is a kind of idiopathic inflammatory myopathy characterized by chronic proximal skeletal muscle weakness and unique skin lesions. However, DM with exfoliation of esophageal mucosa is rare. A 36-year-old male patient complained of muscular soreness of extremities, dysphagia, and pharyngalgia was diagnosed with DM with exfoliation of esophageal mucosa. After treatment with glucocorticoid, immunosuppressant, acupuncture, and endoscopic submucosal dissection (ESD), the above symptoms were disappeared. During the 3-year follow-up period, the results of routine physical examination, laboratory examination, gastroscopy, and imaging examination were normal. High-dose of corticosteroid is needed in the initial treatment, but it must be reduced regularly to avoid adverse reactions. Acupuncture and ESD are also effective as adjuvant therapy.

Role of MDA in the pathogenesis of GERD esophagus mucosal inflammatory injury / 中国医师杂志

Objective To investigate the expression of malondialdehyde ( MDA) in esophageal mu-cosa of different types of gastroesophageal reflux disease ( GERD) patients and its role in the esophageal in-flammation. Methods According to the inclusion and exclusion criteria, 42 patients hospitalized in the the Xinjiang Uygur Autonomous Region People's Hospital from December 2017 to October 2018 were selected as the research group. 8 healthy subjects completed physical examination were set up as healthy control group. GERD completed GERDQ score, 24 h pH monitoring, and taken 3 cm on the dentate line of the esophagus as a specimen. The study group was divided into non-erosive reflux disease (NERD) group (17 cases) and Ero-sive reflux disease [erosive esophagitis (RE)] group (25 cases). Then hematoxylin-eosin (HE) staining, immunohistochemistry, real-time polymerase chain reaction ( qPCR ) , enzyme-linked immunosorbent assay (ELISA) methods were used to detect inflammation, oxidative stress (MDA), antioxidant enzyme [manga-nese superoxide dismutase (Mn SOD), glutathione (GSH), catalase (CAT)], and proinflammatory cyto-kines [monocyte chemotactic protein-1 (MCP-1), interlukin-8 (IL-8), tumor necrosis factorα(TNF-α)]. Results There was no significant difference in body mass index ( BMI ) between the three groups ( P >0. 05). 24 h pH monitoring of esophagus showed that the indexes of weak acid reflux (4<pH<7), acid re-flux ( pH<4 ) , esophageal near end acid reflux (％) and DeMeester score in RE group were significantly higher than those in NERD group, with statistical significance between the groups (P<0. 05). There was no significant difference in esophageal pressure between high resolution groups (P>0. 05). In RE group , the infiltration of immune cells (neutrophils, eosinophils), nipple lengthening, edema and other inflammatory changes were found in the esophageal mucosa, and the inflammation score reached the peak, which was signif-icantly higher than that in NERD group, with statistical significant difference (P<0. 001). The positive ex-pression of MDA in the two groups ( NERD, RE) was higher than that in the control group, and the MDA ex-pression in the RE group was almost covered with the full layer esophagus. The serum MDA concentration in the NERD and RE groups was significantly higher than that in the control group (P<0. 001). Compared with the NERD group, the serum MDA in the RE group reached the peak (P<0. 01). The relative expression of mRNA ( Mn SOD, GSH and CAT) in NERD group and RE group was significantly decreased, and there was a significant difference between the three groups (P<0. 001). Compared with the NERD group, the mRNA expression level of Mn SOD and CAT in RE group was significantly decreased (P<0. 01). The relative ex-pression of mRNA (MCP-1, IL-8, TNF- α) increased significantly in the two groups (NERD, RE), and there was a statistically significant difference between the three groups ( P <0. 001 ) . Compared with the NERD group, the expression of its inflammatory factors in the RE group significantly increased (P<0. 01). Conclusions The expression level of MDA in different types of GERD is significantly higher, which may be closely related to esophageal inflammation induced by acid reflux.

Expression of nitric oxide synthase in esophageal mucosa of patients with gastroesophageal reflex disease / 西安交通大学学报(医学版)

Objective To compare the expression of nitric oxide synthase (NOS ) in patients with gastroesophageal reflex disease (GERD)and healthy controls.Methods The distribution and relative protein amount of two NOS subtypes (nNOS and iNOS)were determined with immunohistological method,and their mRNA levels were measured with real-time PCR method.Results The nNOS and iNOS were mostly distributed in the cytoplasm in epithelia of esophageal mucosa.The nNOS and iNOS in reflux esophagitis (RE)were significantly higher than in non-erosive reflux disease (NERD)patients and healthy controls (P <0.05 ).The mRNA levels of nNOS and iNOS were also significantly higher in RE patients than in NERD patients and healthy controls (P <0.05).Conclusion The expressions of nNOS and iNOS were increased in the esophagus of RE patients,which may be related to the effects of NO on the onset of GERD.

Protection effect of Xuanfudaizhetang on reflux esophagitis in rats

OBJECTIVE@#To study protection effect of Xuanfudaizhetang on reflux esophagitis in rats.@*METHODS@#A total of 50 Wistar rats were randomly divided into groups A, B, C, D and E with 10 in each. Reflux esophagitis model in rats was established by incomplete helicobacter seam+lower esophagus sphincterotomy. All rats were divided into 5 groups: group A as control group, group B as model group, group C with saline lavage treatment, group D with motilium treatment, group E with Xuanfudaizhetang lavage treatment. Recovery of esophageal, gastric mucosa and pH changes of rats were compared between groups.@*RESULTS@#Weight gain in group D and E was significantly higher in than group C; the esophageal mucosa grades and esophagus tissue pathological morphology grades of group D and E were higher than that of group B and C with significant difference between groups (P<0.05); pH of lower esophageal mucosa in group D and E increased significantly than that in the group B and C (P<0.05), and the distal mucosal pH dropped significantly in the group B and C (P<0.05).@*CONCLUSIONS@#Xuanfudaizhetang can obviously improve the pH of lower esophageal mucosa in rats with reflux esophagitis, decrease pH value of gastric mucosal, thus improve esophageal mucosa pathological conditions to achieve therapeutic effect on reflux esophagitis.

Evaluation of the esophageal wall injury resulted from Argon plasma coagulation / 中华消化内镜杂志

Objective To observe the extent of injury in esophageal mucosa resulted from Argon plasma coagulation (APC). Methods The injuries from APC were observed in 55 sites of esophageal normal mucosa in 11 patients with esophageal cancer. APC powers in 45 W,60 W and 90 W were selected with exposure times of 1 sec and 3 sec respectively. The probe of APC was hold approximately at 30?and 2 mm from the mucosa. The histological changes of esophageal wall injured by APC were examined under light and electric microscopy. Results The injuries in 46 out of 55 sites were merely restricted in the mucosa or sub-mucosa,7 out of 55 extended into the muscularis propria.and 2 of 9 sites extended to the whole depth of e-sophageal wall. The depth of injury increased in relation with the elevating of APC power (P 0. 05). Conclusion APC is a safe way for treating esophageal diseases if its power is limited in an appropriate range.