Esophagitis

This article will help you read and understand your pathology report for esophagitis.

by Shaheed Hakim, MD FRCPC, reviewed on November 11, 2020

Quick facts:

• Esophagitis is a medical condition where the cells that line the inside of the esophagus are injured or damaged.
• Esophagitis has many causes although the two most common causes are acid reflux from the stomach and infections.
• Pathologists examine a tissue sample under the microscope to determine the cause.

The anatomy of the esophagus

The esophagus is a long hollow tube that starts at the back of your throat and ends at the top of your stomach. Swallowed food travels down the esophagus into the stomach.

The esophagus is made up of six layers of tissue:

• Epithelium – The epithelium is on the inside surface of the esophagus. The epithelium is made up of cells called squamous cells. The squamous cells connect together to form a barrier that protects the inside of the esophagus from injury.
• Lamina propria – The lamina propria is a thin layer of connective tissue directly below the epithelium. The lamina propria supports the squamous cells.
• Muscularis mucosa – The muscularis mucosa is a thin layer of muscle cells below the lamina propria.
• Submucosa – The submucosa sits directly below the muscularis mucosa. It contains large blood vessels, lymphatic channels, and glands.
• Muscularis propria – The muscularis propria is a thick bundle of muscle in the middle of the wall of the esophagus. The muscularis propria allows the esophagus to move food towards the stomach.
• Adventitia – The tissue on the outer surface of the esophagus is called the adventitia. It surrounds the esophagus and separates is from nearby tissues and organs such as the airway and the aorta.

What is esophagitis?

Esophagitis is a non-cancerous change in the esophagus used to describe inflammation of the epithelium. It is a descriptive diagnosis and many conditions are known to cause esophagitis.

Patients with esophagitis often suffer from pain or difficulty swallowing solid foods. Patients with these symptoms often undergo a procedure known as an upper endoscopy, where a doctor uses a small camera to look at the inner lining of the esophagus.

How do pathologists make this diagnosis?

The diagnosis is usually made after a small tissue sample is removed from the esophagus in a procedure called a biopsy. Your doctor may recommend a biopsy if you have symptoms of esophagitis and to look for a cause.

Common causes of esophagitis

Gastroesophageal reflux disease (GERD)

People with acid reflux disease (also known as gastroesophageal reflux disease or ‘GERD’ for short) experience pain when the acids in their stomach move backwards into the esophagus injuring the squamous epithelium.

The microscopic changes associated with this type of injury include spongiosis (swelling), basal cell hyperplasia (an increased number of cells at the bottom of the epithelium), elongation and congestion of lamina propria papillae (congestion), and inflammation.  In severe cases, ulceration or erosion of the surface epithelium can be seen.

A diagnosis of acute or active esophagitis means that your pathologist has seen these changes under the microscope and that the changes are consistent with the symptoms or endoscopic findings. GERD is the most common cause of acute or active esophagitis, however, the microscopic features can be seen in other types of esophagitis (see below).

Candida esophagitis

Candida fungal organisms are a normal part of our gastrointestinal tract (esophagus, stomach, small intestine, and colon).  Usually these organisms live on the surface of the tissue without causing any reaction from the tissue below. However in some situations, such as in people with diabetes or those who have recently taken antibiotics, the fungal organisms can increase in number and damage the lining of the esophagus.

When viewed with an endoscope, these damaged areas look like white plaques (a raised area of tissue that stands out from the surrounding normal tissue).

A diagnosis of Candida esophagitis means that your pathologist has seen some or all of the changes of esophagitis (described above), often with increased neutrophils (an inflammatory cell), as well as confirmed the presence of the Candida fungal organisms.

Pathologists often use special stains that can highlight these organisms for more easy and accurate identification.

Eosinophilic esophagitis

Eosinophilic esophagitis is essentially an allergic reaction occurring inside your esophagus.  Like in other allergic conditions, allergic esophagitis is associated with the presence of a special type of inflammatory cell called an eosinophil.

A diagnosis of eosinophilic esophagitis means that your pathologist has seen some or all of the features of esophagitis (described above) as well as an increased number of eosinophils.

This diagnosis requires both the microscopic features and the characteristic endoscopic finding of concentric rings or trachealization of the esophagus.

Intestinal metaplasia

Esophagitis that is not treated can damage the squamous epithelium. If the damage continues for many years, a new type of epithelium similar to the epithelium normally found in the small intestine slowly replaces the squamous cells.

The change from squamous epithelium to small intestinal epithelium is an example of intestinal metaplasia. When intestinal metaplasia takes place in the esophagus is referred to as Barrett’s esophagus or Barrett’s disease.

Barrett’s esophagus is a non-cancerous disease. However, it is considered a pre-cancerous disease because the cells in Barrett’s esophagus have the potential to turn into cancer of the esophagus called adenocarcinoma over time.

Importantly, the risk of developing cancer after a diagnosis of Barrett’s esophagus is low. The presence of dysplasia, a type of abnormal cell growth, in Barrett’s esophagus, increases the risk of cancer (see Dysplasia below).

Dysplasia

Dysplasia describes an abnormal pattern of growth that is initially non-cancerous but can turn into cancer over time. Long term inflammation  which leads to intestinal metaplasia, can then lead to dysplasia.

The earliest change is called low grade dysplasia. In some cases, the cells become even more abnormal and progress to high grade dysplasia.

In high grade dysplasia, the abnormal cells look similar to cancer cells but are only seen in the epithelium. Once the cells have spread into the tissue below the epithelium, the diagnosis changes to intramucosal carcinoma, which is essentially an early stage cancer.

Although it is rare, your pathologist will carefully examine the tissue for any evidence of dysplasia.