成人嗜酸细胞性食管炎的临床特征及超声内镜诊断价值

Clinical characteristics and diagnostic value of endoscopic ultrasonography for adult eosinophilic esophagitis

摘要:

目的 探讨成人嗜酸细胞性食管炎（eosinophilic esophagitis，EoE）的临床特征及超声内镜的诊断价值。方法 回顾浙江大学医学院附属第一医院2011—2022年确诊的12例EoE患者资料，分析临床和影像学表现、内镜和超声内镜特征，以及治疗、随访情况。结果 12例EoE患者中男9例、女3例，确诊时平均年龄48.5岁（17~73岁）。2例有哮喘病史，1例有荨麻疹病史，5例存在食物和（或）药物过敏史。症状出现至确诊的时间为2周至30年。临床症状为反酸（8例）、腹部胀痛（8例）、进食后梗阻感（5例）。4例（4/11）外周血嗜酸性粒细胞比例升高，4例（4/10）外周血免疫球蛋白E升高。7例（7/8）食管增强CT提示食管壁增厚，增强扫描可见强化，1例（1/8）显示有多发纵隔淋巴结肿大。普通内镜下表现为黏膜粗糙发白（12例），纵形线性沟犁样改变（5例），环形隆起（4例），颗粒样隆起（1例），管腔狭窄（1例）。8例接受超声内镜检查，均见食管壁增厚，以固有肌层增厚最为常见（5.0~12.5 mm），各层次结构存在，分界欠清。6例予口服激素并逐步减量后停药，临床症状均获显著改善，复查胃镜均见食管黏膜基本恢复正常，活检示食管黏膜嗜酸性粒细胞浸润明显减少或完全缓解，其中2例复查超声内镜，见食管壁及固有肌层增厚情况较前明显减轻、改善；5例接受抑制胃酸治疗后临床症状反复，其中2例复查胃镜，食管黏膜活检提示仍有嗜酸性粒细胞浸润。结论 成人EoE临床表现易与胃食管反流病等混淆，内镜下典型表现为黏膜粗糙、发白，纵形线性沟犁样改变，环形隆起，颗粒样隆起与管腔狭窄等。超声内镜可用于EoE患者的诊断、鉴别诊断以及食管壁重塑情况和疗效的客观评估。成人EoE患者单纯应用抑酸治疗效果欠佳，口服激素治疗可取得良好的临床疗效与病理学缓解。

Abstract:

Objective To investigate the clinical characteristics of adult eosinophilic esophagitis (EoE) and the diagnostic value of endoscopic ultrasonography (EUS). Methods Data from 12 adult patients with EoE diagnosed at the First Affiliated Hospital of Zhejiang University School of Medicine from 2011 to 2022 were retrospectively analyzed for the clinical manifestations, imaging and endoscopic findings, EUS characteristics, treatment and prognosis. Results Among the 12 EoE patients, 9 were male and 3 were female, with a mean age at diagnosis of 48.5 years (17-73 years). Two patients had a history of asthma, 1 had urticaria, and 5 had a history of food and/or drug allergy. The time from symptom onset to diagnosis ranged from 2 weeks to 30 years. The most common clinical symptoms were acid regurgitation (8 cases), abdominal pain (8 cases), and obstruction dysphagia (5 cases). Four (4/11) patients had increased peripheral blood eosinophils and 4 (4/10) patients had increased peripheral blood immunoglobulin E. Contrast-enhanced CT of the esophagus showed esophageal wall thickening and enhancement in 7 patients (7/8). One (1/8) patient showed multiple mediastinal lymph nodes enlargement. Under endoscopy, edema (12 cases), linear furrows (5 cases), rings (4 cases), exudates (1 case), and luminal narrowing (1 case) were observed in the mucosa. Eight patients underwent EUS, and all of them showed esophageal wall thickening, and the muscularis propria thickening being the most common (5.0-12.5 mm), with various hierarchical structures and unclear boundaries. Topical corticosteroid therapy led to significant symptom improvement and mucosal healing in 6 patients. Biopsy showed that the infiltration of eosinophils in the esophageal mucosa was significantly reduced or completely relieved. The clinical symptoms recurred in 5 patients after receiving acid suppression therapy, and 2 of them still had eosinophil infiltration in esophageal mucosal. Conclusion The clinical presentation of EoE in adults can mimic gastroesophageal reflux disease, highlighting the importance of accurate diagnosis. The typical endoscopic findings of EoE are edema, linear furrows, rings, exudates and luminal narrowing. EUS can be used for the diagnosis, differential diagnosis, and objective evaluation of esophageal wall remodeling in patients with EoE. Adult patients with EoE have poor response to antacid therapy alone, while topical corticosteroid therapy can achieve good clinical efficacy and pathological remission.