Utility of Cardia Biopsies in the Distinction between Reflux Esophagitis and Eosinophilic Esophagitis in Pediatric Patients
R Wilcox, L Hormaza, A Noffsinger, J Hart. University of Chicago, Chicago, IL
Background: Eosinophilic esophagitis (EE) is an increasingly recognized clinicopathologic diagnosis. There is tremendous overlap in clinical and histologic features between EE and gastroesophageal reflux disease (GERD). Differentiation is important as treatment differs between the 2 disorders. According to the latest consensus guidelines, >15 eosinophils in one HPF is diagnostic of EE in the proper clinical context; however, EE is often patchy and significant overlap in eosinophil counts exist with GERD. In the adult population, a strong correlation between carditis and GERD has been established. In children the presence and significance of gastric cardia and carditis is still being established. The objective of our study was to determine if the presence of carditis could be used to histologically differentiate between GERD and EE in the pediatric population.
Design: 41 patients (pts), 16 months to 18 yrs of age, presenting for upper endoscopy were prospectively enrolled. Two additional biopsies from the gastric cardia straddling the EG junction were obtained in each pt. Three GI pathologists reviewed the biopsies and documented the presence of cardia +/- carditis (defined as neutrophilic inflammation or dense mononuclear cell infiltrate). Cardiac lamina propria eosinophil counts were also performed. Each patient's chart was reviewed to document symptoms, medication history, therapy response, allergic evaluation including RAST and pH probe monitoring. Based on clinicopathologic consensus pts were placed in 1 of 5 categories: Normal, EE, Treated EE, GERD, Co-existent (clear evidence for both EE and GERD).
Results: Cardiac mucosa was successfully obtained in 32 pts with 8 positive for carditis. If carditis was present the patient had GERD and no EE pt had carditis (PPV=100%).
Eosinophils were rare in normal cardiac lamina propria (range 0-1/HPF). Although increased in both, the mean numbers of cardia eosinophils did not significantly differ between EE and GERD pts, while in treated EE pts the count dropped to the normal range (0-1/HPF). Intestinal metaplasia was not identified in any patient.
Conclusions: Biopsies of the gastric cardia can be used to distinguish reflux esophagitis from EE in the pediatric population. Carditis occurs only in GERD or co-existent GERD/EE pts and not in EE alone.
Monday, March 9, 2009 8:30 AM
Platform Session: Section C, Monday Morning