NoteFor esophageal biopsies, I often like to start by saying the type of mucosa I see (i.e., gastric-type, squamous, or squamocolumnar mucosa) to help with endoscopic-microscopic correlation when evaluating for metaplasia and localization of the GE-junction.


Acute Esophagitis 

 Squamous mucosa with acute esophagitis

 Fungal organisms morphologically consistent with candida species identified

 Squamous mucosa with acute esophagitis and ulceration

 Herpes viral inclusions identified

Squamous mucosa with acute esophagitis (see comment)

COMMENT: The distal esophageal biopsy shows numerous neutrophils within the superficial squamous mucosa. No fungal organisms are present on the H&E-stained slide. However, a special PAS stain for fungus has been ordered and will be reported in an addendum. No viral cytopathic changes or pill fragments are identified. The differential diagnosis also includes reflux esophagitis. Clinical and endoscopic correlation is required.


– Squamous mucosa with active esophagitis and ulceration

– Extracellular resins, consistent with Kayexalate identified (see comment)

COMMENT: The biopsy shows *** mucosa with characteristic Kayexalate resins within the area of ulceration. This is of note because Kayexalate has been associated with gastrointestinal injury and sometimes even severe necrosis (see reference below).  Clinical and endoscopic correlation is required.

These findings were discussed with Dr. *** by Dr. *** on *** at ***.

REFERENCE: Abraham SC et al. Upper gastrointestinal tract injury in patients receiving kayexalate (sodium polystyrene sulfonate) in sorbitol: clinical, endoscopic, and histopathologic findings. Am J Surg Pathol. 2001 May;25(5):637-44.



Reflux Esophagitis (<5 Eos/HPF) 

 – Squamous mucosa with reflux esophagitis


 – Squamous mucosa with findings suggestive of reflux esophagitis



Either reflux or eosinophilic esophagitis (5-15 Eos/HPF in distal biopsy) 

– Squamous mucosa with increased intraepithelial eosinophils (with up to *** eosinophils per single high-power field) (see comment)

COMMENT: The esophageal biopsy shows squamous mucosa with basal cell hyperplasia, intraepithelial edema, and moderately increased intraepithelial eosinophils (with up to *** eosinophils per single high-power field). The primary differential diagnosis includes reflux esophagitis and eosinophilic esophagitis. Clinical and endoscopic correlation is recommended. Additionally, paired biopsies of the proximal, mid, and distal esophagus could be considered.



Eosinophilic Esophagitis 

Eosinophils more or equally numerous proximally or in the distal biopsy and >20 Eos/HPF

– Squamous mucosa with eosinophil-rich esophagitis (with up to *** eosinophils within a single high-power field) (see comment)

COMMENT: The esophageal biopsy shows squamous mucosa with increased intraepithelial eosinophils (with up to *** eosinophils within a single high-power field) with eosinophil microabscess formation, basal cell hyperplasia, and eosinophil degranulation. These findings are consistent with eosinophilic esophagitis in the appropriate clinical context. Clinical and endoscopic correlation is recommended.



Lymphocytic Esophagitis 

Marked lichenoid injury pattern with numerous intraepithelial lymphocytes (and not dramatically increased Eos or neutrophils)

– Squamous mucosa with lymphocytic esophagitis (see comment)

COMMENT: The esophageal biopsy shows squamous mucosa with increased intraepithelial lymphocytes with a prominent lichenoid pattern of injury with numerous apoptotic keratinocytes (“Civatte bodies”).  This pattern of injury is nonspecific and can be seen in association with gastroesophageal reflux (GERD), cutaneous lichen planus, contact mucositis, graft-versus-host disease,  certain medications (including NSAIDs, among many others), viral infections, Crohn’s disease, treated eosinophilic esophagitis, and pill esophagitis. An immunohistochemical stain for CMV is negative. Clinical and endoscopic correlation is recommended.


Sloughing esophagitis 

 – Squamous mucosa with findings consistent with esophagitis dissecans superficialis (sloughing esophagitis) (see comment)

COMMENT:  The endoscopic impression of “diffuse sloughing of the epithelium consistent with esophagitis dissecans” is noted.  Indeed, the esophageal biopsies demonstrate a preserved basal layer with “mummified” cells in the superficial layers with “ghost” nuclei, parakeratosis, and fragmentation.  Inflammation is not prominent.  Although the etiology of this disorder is usually unknown, the condition has been associated with some medications, bullous dermatoses, motility disorders, physical/thermal injury, and autoimmune diseases.  Clinical and endoscopic correlation is recommended.


Esophageal leukoplakia/Epidermoid metaplasia 

 – Squamous mucosa with esophageal leukoplakia/epidermoid metaplasia (see comment)

COMMENT: The esophageal biopsies show squamous mucosa with orthokeratosis and hypergranulosis, consistent with esophageal leukoplakia/epidermoid metaplasia, in the appropriate clinical setting. This uncommon finding is associated with distal esophageal dysmotility disorders, including scleroderma, and factors associated with oral leukoplakia, such as tobacco and alcohol usage. Currently, it is thought that these patients have an increased risk of squamous dysplasia/carcinoma, prompting some to recommend periodic surveillance. In this case, there is no evidence of dysplasia.


Barrett’s Esophagus 

– Squamocolumnar mucosa with intestinal metaplasia, Negative for dysplasia




  – Squamous papilloma

  – Squamous intraepithelial neoplasia (dysplasia), Low-grade

  – Squamous intraepithelial neoplasia (dysplasia), High-grade

  – Squamous cell carcinoma, at least in situ

  – Invasive squamous cell carcinoma

Glandular (derived from Barrett’s)

  – Intestinal metaplasia with low-grade dysplasia (glandular intraepithelial neoplasia)

  – Intestinal metaplasia with high-grade dysplasia (glandular intraepithelial neoplasia)

  – Adenocarcinoma, at least intramucosal

  – Invasive adenocarcinoma (see comment)

COMMENT: The esophageal mass biopsy show an invasive adenocarcinoma with a predominantly *** pattern of growth.  There is *** gland formation consistent with a provisional WHO grade of *** . No signet ring cells are identified.

Note: “Patterns” of growth: 1) Tubular (most common), 2) Papillary, 3) Mucinous, or 4)Signet ring


Last updated: 5/20/2024