When reviewing esophageal biopsies, the goal is to categorize findings into actionable diagnostic patterns. Using a “Low Power Examination” strategy, we can break down complex slides into four primary pillars.
1. Parakeratosis & Candida
If you see parakeratosis (nuclei retained in the keratin layer), your first instinct should be to look for fungi. This is a classic sign of Candida esophagitis.
2. Hyperplastic Mucosa
Not all thickened mucosa is the same. We look for two specific clues:
- Clear Cell Features: Often indicates Glycogenic Acanthosis, a benign accumulation of glycogen in squamous cells.
- Pseudoepitheliomatous Hyperplasia (PEH): If the epithelium looks overly reactive and “tongue-like,” look deeper—it may be reacting to an underlying Granular Cell Tumor.
3. Ulcer
If a true ulcer is present, the diagnosis usually falls into one of three buckets:
- Infections: Viral (HSV/CMV) or Fungal.
- Pill Injury: Chemical irritation from medications.
- Reflux Esophagitis: Look for elongated rete ridges and basal cell hyperplasia.
4. The Granular Layer Warning
The normal esophagus does not have a granular layer. If you find one, it is Epidermoid Metaplasia. This is a critical diagnosis because it serves as a precursor to Esophageal Squamous Cell Carcinoma (SCC).
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