Rings in the esophagus are not always eosinophilic esophagitis: Case series of ring forming lymphocytic esophagitis and review of the literature

Abstract

Background and study aims Lymphocytic esophagitis (LyE) is a form of chronic esophagitis characterized by edema and lymphocytic infiltration of the epithelial peripapillary fields, without eosinophils. Its significance is unclear, as it was previously thought to have little clinical impact. More recent literature, however, describes a paradigm shift suggesting a distinct entity. We report on 3 patients with dysphagia who were found to have esophageal rings on endoscopy. Histology was consistent with LyE. Additional features reported in this cohort included an esophageal web, esophageal pseudodiverticula and esophageal erythema. We also report a current literature review of the topic. The literature review reported here includes another 37 patients with LyE and rings, for a total of 40 patients. Patients with LyE may present with esophageal rings and other findings. LyE should be considered in the differential diagnosis of esophageal rings.

Lymphocytic esophagitis: an update on histologic diagnosis, endoscopic findings, and natural history

“…3 Biopsy samples from these individuals often show intraepithelial lymphocytosis far in excess of 20 lymphocytes per high-power field accompanied by mucosal edema and dyskeratotic cells. 19 Taken together, the data suggest that esophageal lymphocytosis is a nonspecific histologic finding that may be encountered in a variety of different situations including dysmotility, gastroesophageal reflux disease, infection, and immune-mediated disorders. Thus, a diagnosis of lymphocytic esophagitis should be refined in order to be clinically meaningful.…”

“…In up to one‐third of patients, the mucosa may be completely normal, while in others the mucosal surface shows rings, furrows, as well as strictures similar to those seen in patients with EoE (Fig. ) . EoE‐like changes seem to develop throughout the esophagus, with the mid‐esophagus being usually involved in conjunction with involvement of the proximal or distal esophagus.…”

“…In our experience, patients with diffuse esophageal lymphocytosis, or lymphocytosis proximal to the gastroesophageal junction, tend to be women, who frequently have immune‐mediated disorders that include collagen vascular disease, Crohn's disease, and celiac disease, and display diffuse mucosal abnormalities in the esophagus . Biopsy samples from these individuals often show intraepithelial lymphocytosis far in excess of 20 lymphocytes per high‐power field accompanied by mucosal edema and dyskeratotic cells …”

“…They concluded that 83% of patients with EoE have at least one abnormality on endoscopy. A review of all the clinical studies and case reports published thus far includes 456 patients with lymphocytic esophagitis . Of these, endoscopic abnormalities were described in 359 (79%) patients.…”

“…1). 1,3,4,6,7,11,13,[17][18][19][20][21][22][23][24][25][26][27] EoE-like changes seem to develop throughout the esophagus, with the mid-esophagus being usually involved in conjunction with involvement of the proximal or distal esophagus. In fact, in a study by Xue et al, most biopsies from the mid-esophagus were found to have a higher intraepithelial lymphocyte count compared to biopsies obtained from other parts of the esophagus.…”