Copyright ©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Apr 28, 2019; 25(16): 1928-1935
Published online Apr 28, 2019. doi: 10.3748/wjg.v25.i16.1928
Upper gastrointestinal tract involvement of pediatric inflammatory bowel disease: A pathological review
Dua Abuquteish, Juan Putra
Dua Abuquteish, Juan Putra, Division of Pathology, Department of Paediatric Laboratory Medicine, Hospital for Sick Children, Toronto, ON M5G 1X8, Canada
Author contributions: Abuquteish D reviewed the literature and drafted the manuscript; Putra J provided overall intellectual input, reviewed the literature, acquired the histological images, and edited the final version of the manuscript; all authors approved the final version to be published.
Conflict-of-interest statement: The authors have no conflicts of interest to disclose.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Juan Putra, MD, Staff Physician, Division of Pathology, Department of Paediatric Laboratory Medicine, Hospital for Sick Children, 555 University Ave, Toronto, ON M5G 1X8, Canada.
Telephone: +1-416-8135966 Fax: +1-416-8135974
Received: March 19, 2019
Peer-review started: March 19, 2019
First decision: March 27, 2019
Revised: April 3, 2019
Accepted: April 10, 2019
Article in press: April 10, 2019
Published online: April 28, 2019

Upper gastrointestinal (UGI) tract involvement of inflammatory bowel disease (IBD) is commonly seen in pediatric patients. Upper endoscopy is included in the routine workup of children with suspected IBD to enhance the diagnosis and management of these patients. Currently, childhood IBD is classified into ulcerative colitis (UC), atypical UC, Crohn’s disease (CD) and IBD unclassified. Histologic confirmation of UGI tract involvement, in particular the presence of epithelioid (non-caseating) granulomas, is helpful in confirming the diagnosis of IBD and its classification. Herein, we reviewed selected IBD-associated UGI tract manifestations in children. Lymphocytic esophagitis, seen predominantly in CD, is histologically characterized by increased intraepithelial lymphocytes (> 20 in one high-power field) in a background of mucosal injury with absence of granulocytes. Focally enhanced gastritis is a form of gastric inflammation in pediatric IBD marked by a focal lymphohistiocytic pit inflammation with or without granulocytes and plasma cells in a relatively normal background gastric mucosa. Duodenal inflammation seen in children with IBD includes cryptitis, villous flattening, increased intraepithelial lymphocytes, and lamina propria eosinophilia. Finally, epithelioid granulomas not associated with ruptured gland/crypt are a diagnostic feature of CD. The clinicopathologic correlation and differential diagnosis of each microscopic finding are discussed. Clinicians and pathologists should be cognizant of the utility and limitations of these histologic features.

Keywords: Pediatric, Inflammatory bowel disease, Lymphocytic esophagitis, Focally enhanced gastritis, Epithelioid granuloma, Crohn’s disease, Ulcerative colitis

Core tip: Upper gastrointestinal tract inflammation is frequently observed in pediatric patients with inflammatory bowel disease. Distinct inflammatory patterns such as lymphocytic esophagitis and focally enhanced gastritis are helpful in rendering the diagnosis of inflammatory bowel disease in an otherwise non-specific case. Epithelioid granulomas are the only specific microscopic finding to distinguish Crohn disease from ulcerative colitis. Meanwhile, duodenal inflammation demonstrates various non-specific histologic findings in the setting of pediatric inflammatory bowel disease. This review highlights the diagnostic criteria and differential diagnosis of each pathologic finding.