Esophagitis1文档格式.docx
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Esophagitis1文档格式.docx
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Frequency:
∙IntheUS:
Unknown
∙Internationally:
Mortality/Morbidity:
Patientsmayexperiencedysphagia,pain,odynophagia,andmalnutritioninsevereesophagitis.Rarely,life-threateningbleedingoccursandmayleadtodeath.Outcomesandsurvivalinthesepatientsarerelatedtotheseverityoftheirunderlyingsystemicillness.
Race:
Noracepredilectionisobserved.
Sex:
Nosexpredilectionisobserved.
Age:
Noage-relateddifferencesarereported;
however,thisconditionisuncommoninchildhood
CLINICAL
History:
Ahistoryofimmunosuppression,steroidtherapy,recentantibioticuse,orsystemicillnesssupportsthediagnosis.Althoughpatientsmaybeasymptomatic,typicalsymptomsincludethefollowing:
∙Onsetofdifficultorpainfulswallowing(ie,dysphagia,odynophagia)
∙Heartburn
∙Retrosternaldiscomfortorpain
∙Nausea,vomiting
∙Fever,sepsis
∙Abdominalpain
∙Epigastricpain
∙Occasionally,hematemesis
∙Anorexia,weightloss(dependsonchronicityandseverityofunderlyingillness)
∙Cough
Physical:
∙Lookforsignsofimmunosuppressionandskinsignsofsystemicdisease,eg,telangiectasiasandsclerodactylyinscleroderma.
∙Examinetheoralcavity(forthrushorulcers).
Causes:
SeeHistologicFindings.
∙Infectiouscausesincludethefollowing:
oCandidaspecies
oNoncandidalfungi(eg,Aspergillus,Histoplasma,Cryptococcus,Blastomyces)
oHerpessimplexvirus(HSV)
oCytomegalovirus(CMV)
oVaricella-zostervirus(VZV)
oEpstein-Barrvirus(EBV)
oInHIV-infectedhosts-CMV,HSV,Mycobacteriumavium-intracellulare,idiopathic
oHumanpapillomavirus(HPV)
oPoliovirus
oBacterialspecies(eg,normalflora,Mycobacteriumtuberculosis,Mycobacteriumavium-intracellulare,other)
oParasiticinfections(eg,Chagasdisease,Trypanosomacruzi,Cryptosporidium,Pneumocystis,Leishmaniadonovani)
∙Systemicillnessesincludethefollowing:
oSkindisorders
▪Epidermolysisbullosa
▪Pemphigusvulgaris
▪Bullouspemphigoid
▪Cicatricialpemphigoid
▪Drug-inducedskindisorders(eg,erythemamultiforme,Stevens-Johnsonsyndrome,toxicepidermalnecrolysis)
▪Otherskindisorders(eg,lichenplanus,psoriasis,acanthosisnigricans,leukoplakia)
oEosinophilicesophagitis
oBeh鏴tdisease
oGraftversushostdisease(GVHD)
oInflammatoryboweldisease
oSarcoidosis
oChronicgranulomatousdisease
oMetastaticcancer
oCollagenvasculardisease
oMedications
▪Pillesophagitis,eg,Fosamax
▪Antibiotics,eg,tetracycline
▪Potassium
▪Nonsteroidalanti-inflammatorydrugs(NSAIDs)
▪Quinidine
▪Chemotherapy(eg,dactinomycin,bleomycin,cytarabine,daunorubicin,5-fluorouracil,methotrexate,vincristine)
oRadiationtherapy
DIFFERENTIALS
AnginaPectoris
GastroesophagealRefluxDisease
PepticUlcerDisease
PulmonaryEmbolism
OtherProblemstobeConsidered:
Coronaryarterydisease
Pericarditis
Aorticaneurysm
Nonulcerrefluxdisease
Functionaldyspepsia
Stricture
WORKUP
LabStudies:
∙CBCcountinneutropenicorimmunosuppressedpatients
∙CD4countandHIVtestinpatientswithriskfactorsforHIV
ImagingStudies:
∙Bariumstudiesarerecommendedastheinitialimagingstudyinpatientspresentingwithdysphagia.
oAcasecanbemadeforinitialupperendoscopybecausethisapproachwouldrevealmorediagnosticinformation(eg,inflammatorycharacteristics,abilitytoobtainsamplesforpathologicalexamination,cytologicalexamination,viralandbacterialcultures).Bariumstudiesarelessaccurateformucosaldetailandcanalsoreducethecapabilityofobtainingpositivecultures.
oTheauthorsdonotrecommendbariumstudiesforpatientswithabsolutedysphagiaorodynophagia.Upperendoscopywouldberecommendedunderthesecircumstances.Theauthorsviewbariumstudiesandupperendoscopyascomplementaryratherthancompetingtestsintheevaluationofpatientswithdysphagia.
OtherTests:
∙Nospecificothertestsarerecommended;
othertestsareperformedbasedonunderlyingdisease,eg,CD4countinHIV,CBCcountinneutropenia,andcollagenworkup(eg,antinuclearantibody[ANA],anti-dsDNA).
Procedures:
∙Esophagogastroduodenoscopy(EGD)ispreferredinpatientswithodynophagiabecausethisisaspecificsymptomofesophagitis.EGDisthemaindiagnostictoolusedforesophagitis.
oAllowsmucosalvisualization
oCanobtainmucosalbiopsiesandbrushings
oWidevarietyoffindingsbasedontheunderlyingcause
∙Blindbrushcytologyhasbeenusedinthepast;
however,withtheavailabilityofEGD,itsusehasdiminished.Itisperformedbypassingacytologybrushinasheathsimilartoanasogastricororogastrictube.Oncetheendofthecatheterisinthemidesophagus,thebrushisextendedandbrushingsaretaken.Finally,thebrushiswithdrawnbackintothesheath.Thisisperformedwithoutanydirectvisualization,asoccurswhenbrushingsareperformedduringanEGD.
HistologicFindings:
Candida
Oralthrushisafrequentfindingandisoftenanindicatorofesophagealinvolvement.Oralthrushcanbeabsentin25%ofcasesofCandidaesophagitis.Candidainfectionisfrequentlyasymptomatic.
Thegradingscaleforcandidalesophagitisisasfollows:
∙Grade1-Fewraisedwhiteplaquesupto2mminsize,noulceration
∙Grade2-Multipleraisedwhiteplaquesmorethan2mminsize,noulceration
∙Grade3-Confluent,linear,nodular,elevatedplaqueswithulceration
∙Grade4-Grade3withnarrowedlumen
Candidaplaquesaretypicallycreamywhiteorpaleyellow,withunderlyingrawmucosa.Brushingsshouldbeobtainedwithasheathedcytologybrush,spreadontoslides,andstainedwithperiodicacid-Schiff,silver,orGramstains.Thepresenceofmycelialformsandmassesofbuddingyeastisconsistentwithcandidalinfection.CulturesareseldomindicatedbecauseCandidaspeciesarecommensalorganisms,anddifferentiatingnormalflorafrominfectionisdifficult.CulturesareusefulforresistantCandidaorAspergillus.
Herpessimplexvirus
HSVesophagitisdiagnosisismadeatendoscopy.Theearliestesophageallesionsarerounded1-to3-mmvesiclesinthemiddletodistalesophagus.Centerssloughtoformdiscretecircumscribedulcerswithraisededges.
AdvancedHSVesophagitismaybeindistinguishablefromcandidalesophagitis.Plaques,cobblestoning,orashaggyulcerativeappearanceisobserved.
HSVpreferentiallyinfectsepithelialcells.Biopsyshouldbeperformedonulcermarginsofislandsofsquamousmucosaforhistologyandculture(seeImage1).
TheulcerbaseisdevoidofepithelialcellsandisinadequatetodiagnoseHSVesophagitis.
Immunologicstainingofcentrifugationculturesismoresensitivethanroutinehistology.
∙Multinucleatedgiantcells
∙Ballooningdegeneration
∙GroundglassintranuclearCowdrytypeAinclusionbodies
∙Marginationofchromatin
ImmunohistologicstainsusingmonoclonalantibodiestoHSVantigensorinsituhybridizationtechni
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