How to manage a patient with suspected lymphocytic esophagitis (LSBE) based on esophagogastroduodenoscopy (EGD) findings?

Management of Suspected Lymphocytic Esophagitis (LSBE) on EGD

Obtain esophageal biopsies immediately during the index endoscopy to confirm the diagnosis histologically, as lymphocytic esophagitis cannot be diagnosed by endoscopic appearance alone and requires demonstration of dense peripapillary lymphocytic infiltrate without significant eosinophilic or neutrophilic infiltrates. 1

Immediate Diagnostic Steps During Index EGD

• Take multiple biopsies from at least 2 levels of the esophagus (minimum 6 biopsies total in four-quadrant fashion every 1-2 cm), as the inflammation can be patchy distributed and you must rule out eosinophilic esophagitis (EoE) which can appear identical endoscopically 1, 2

• Document whether the patient is currently taking proton pump inhibitors (PPIs) and for how long on both the endoscopy report and histology request form, as PPIs can suppress eosinophil counts below diagnostic thresholds and obscure an EoE diagnosis 1

• If the patient has been on PPIs, the diagnosis of lymphocytic esophagitis cannot be definitively made until repeat endoscopy is performed after at least 3 weeks off PPI therapy to exclude EoE-like disease 1

Critical Differential Diagnosis Considerations

The primary concern with endoscopic changes suspicious for LSBE is distinguishing it from eosinophilic esophagitis, as both conditions present similarly:

• Both can show rings, furrows, edema, exudates, and strictures endoscopically 1, 3, 4
• Both predominantly affect patients with dysphagia (approximately two-thirds of LSBE patients) 1
• The key histologic difference is that LSBE shows dense peripapillary lymphocytic infiltrate (CD3+/CD4+/CD8+ T cells) without significant eosinophils, while EoE requires ≥15 eosinophils per 0.3 mm² 1, 2, 4

You must also rule out Crohn's disease, as it can present with similar histopathologic features, particularly in pediatric patients 1, 5

Management Algorithm Based on Initial Biopsy Results

If Initial Biopsies Show LSBE Pattern (Dense Lymphocytes, Minimal Eosinophils):

Do NOT accept this diagnosis as final if the patient was on PPIs at the time of biopsy. 1

1. Discontinue PPIs for at least 3 weeks 1
2. Repeat endoscopy with adequate biopsies (minimum 6 from different esophageal levels) to definitively exclude EoE 1, 2
3. If repeat biopsies off PPI still show LSBE pattern, proceed with LSBE-directed therapy 1, 5

If Biopsies Show <15 Eosinophils per HPF but Endoscopic Features Suggest EoE:

Repeat endoscopy is mandatory in patients with suggestive endoscopic features or typical symptoms (dysphagia, food bolus obstruction) whose initial histology was not diagnostic for EoE 1

• 36% of such patients will have diagnostic EoE histology on repeat biopsy 1
• Ensure no dietary exclusions are in place that may mask results 1
• Confirm PPIs have been discontinued for at least 3 weeks 1

Treatment Approach for Confirmed LSBE

Once LSBE is confirmed (after excluding EoE and Crohn's disease), treatment options are limited and empiric:

First-Line Therapy:

Initiate high-dose PPI therapy (20-40 mg twice daily) for 8-12 weeks, as this is the most commonly used and safest initial approach 1, 6, 5

• PPIs have anti-inflammatory effects beyond acid suppression, including restoration of esophageal mucosal barrier function 6
• Take PPIs 30-60 minutes before meals for optimal efficacy 6

Second-Line Therapy if PPI Fails:

Consider swallowed topical corticosteroids (budesonide or fluticasone), using the same formulations and dosing as for EoE 1, 7, 5

• Budesonide oral suspension or fluticasone propionate mixed with viscous vehicle, swallowed twice daily 7
• Perform repeat endoscopy with biopsies at 8-12 weeks to assess histological response, as symptoms do not correlate with inflammation 7

Management of Strictures:

If strictures are present causing dysphagia, perform endoscopic dilation (balloon or bougie) 7, 5, 4

• One session of endoscopic balloon dilation can dramatically improve dysphagia in LSBE patients with strictures 4
• Combine dilation with anti-inflammatory therapy (PPI or topical steroids) for better long-term outcomes 7

Critical Pitfalls to Avoid

• Never diagnose LSBE in a patient currently taking PPIs without repeat biopsy off therapy, as you may miss EoE 1
• Never rely on endoscopic appearance alone – LSBE and EoE are endoscopically indistinguishable 1, 3
• Never take fewer than 6 biopsies from at least 2 esophageal levels, as inflammation is patchy 1, 2
• Never assume symptom improvement means histological remission – always confirm with repeat endoscopy and biopsy 7
• Do not forget to rule out Crohn's disease, especially in younger patients 1, 5

Follow-Up Strategy

Repeat endoscopy with biopsies at 8-12 weeks after initiating therapy to assess histological response, regardless of symptom improvement 6, 7

• If symptoms persist despite therapy and histology shows ongoing inflammation, consider referral to gastroenterology with expertise in esophageal disorders 7
• Long-term maintenance therapy may be needed, as LSBE can be a chronic condition with recurrent stricture formation 4