Chronic esophagitis dissecans: an unrecognized clinicopathologic entity?

[Esophagitis dissecans superficialis: two cases of the same rare entity]

Esophagitis dissecans superficialis (EDS) is a rare disease characterized by sloughing of the superficial esophageal mucosa and, histologically, by the bitonal appearance of the squamous epithelium secondary to necrosis of the most superficial layers. Etiology is uncertain, however, it has been associated with some medications, autoimmune diseases, esophageal stasis and endoscopic procedures. Here, two cases are presented, one of them which appeared in a woman after an episode of dysphagia and another one which occurred to a man with comorbidities and epigastric pain. This entity should be considered due to its self-limiting clinical course, compared to other entities with a more torpid evolution or that require more specific treatment.

Non eosinophilic chronic stricturing esophagitis: Lessons from thirty eight cases

BACKGROUND AND AIMS

The endoscopic workup of dysphagia can lead to the diagnosis of atypical esophagitis, with thickened esophageal mucosa, strictures, mucosal exudates, furrows, and sloughing. While these aspects suggest eosinophilic esophagitis, pathology might not report the presence of eosinophils, but rather chronic inflammation, with spongiosis, parakeratosis, and lymphocytic infiltrate. We aimed to report the management of this disease and assess the prevalence of associated dermatological conditions.

METHODS

We retrospectively evaluated the medical records of our patients with non-eosinophilic stricturing esophagitis for clinical, endoscopy, and pathology data. Patients were evaluated by a dermatologist. A blood immunoassay and skin biopsy were performed if needed.

RESULTS

Thirty-eight patients (twenty-six women) were included in the study. The median age at onset of symptoms was 56.5 years, with a median duration of symptoms of two years. Thirty-five patients presented with dysphagia at diagnosis and eighteen with weight loss. At endoscopy, a single esophageal stenosis was diagnosed in 19 patients, localized in the upper third in 22 patients. Thirty patients received endoscopic treatment (dilatation in 29/38 and local triamcinolone injection in 11/38 patients). In 21 patients, oral, skin or vulvo-anal lesions were found on dermatological examination. Nineteen patients received systemic treatment, including corticosteroids, immunosuppressive drugs and plasmapheresis. Five patients developed esophageal squamous cell carcinoma.

CONCLUSION

The management of non-eosinophilic chronic stricturing esophagitis is challenging, because of a low contribution of esophageal biopsies and the refractory nature of the strictures. In our experience, a dermatological evaluation helped in 55% of cases to introduce a systemic treatment, leading to limit the use of endoscopic dilatation. Endoscopic follow-up is needed, considering the significant risk of esophageal squamous cell carcinoma.

Novel and rare forms of oesophagitis

Our understanding of inflammatory diseases of the gastrointestinal tract, including those of the oesophagus, has expanded in recent years. Once attributed almost exclusively to gastro-oesophageal reflux disease or infection, it is now recognised that oesophagitis may occur due to a variety of distinct disease entities. Many of these conditions cause debilitating and persistent symptoms, impacting upon quality of life and necessitating ongoing surveillance and treatment. This review will consider the clinical, endoscopic and histopathological features of these novel and rare forms of oesophagitis.

Sloughing esophagitis: a spectacular histologic and endoscopic disease without a uniform clinical correlation

Sloughing esophagitis, also currently known as esophagitis dissecans superficialis, is a degenerative disease of the squamous epithelium characterized by superficial epithelial necrosis with parakeratosis, but without inflammation, and detachment of the superficial necrotic zone from the deep viable zone. This leads to a spectacular endoscopic appearance of sloughed mucosa in streaks and patches. The cause is unknown, and the clinical characteristics are variable, ranging from incidentally findings to esophageal symptoms. The disease seems to be self-limited, as resolution of the changes was observed in the few cases for which follow-up endoscopic examinations have been reported.

Esophagitis Dissecans Superficialis: Clinical, Endoscopic, and Histologic Features

BACKGROUND

Esophagitis dissecans superficialis (EDS) is a desquamative disorder of the esophagus, but there is a paucity of the literature regarding this condition.

AIM

We examined our institution's experience to further characterize clinical outcomes, and endoscopic and histopathologic features.

METHODS

Endoscopy and pathology databases were retrospectively reviewed from 2000 to 2013 at Mayo Clinic Rochester to identify potential cases of EDS. Medical records and endoscopic images were reviewed to identify cases, and original pathologic specimens were also reviewed. Clinical, endoscopic, and histologic characteristics of EDS were defined.

RESULTS

Forty-one subjects were identified with a median age at diagnosis of 65.0 years (IQR 52.8-76.1) and a female preponderance (63.4 %). Many patients were taking a psychoactive agent (73.1 %) or acid-suppressive therapy (58.5 %) preceding the index endoscopy. Strips of sloughed membranes had a predilection for the distal and/or middle esophagus and resolved in 85.7 % of subjects at endoscopic follow-up. Parakeratosis and intraepithelial splitting were histologic features seen in all patients, while splitting of the connective tissue and intraepithelial bullae were seen in 46.2 and 11.1 %, respectively. There were no disease-related complications at a median follow-up of 10.4 months (IQR 1.2-17.2).

CONCLUSIONS

EDS is likely under-recognized. A distinct endoscopic feature of EDS is "sloughing" strips of mucosa with parakeratosis and intraepithelial splitting being sine qua non histologic findings. The use of psychoactive agents (particularly a SSRI or SNRI) was prevalent at endoscopic diagnosis, although the clinical relevance of this is uncertain. EDS appears to be a benign, incidental finding without complications.

Oesophageal dysphagia: manifestations and diagnosis

Oesophageal dysphagia is a common symptom, which might be related to severe oesophageal diseases such as carcinomas. Therefore, an organic process must be ruled out in the first instance by endoscopy in all patients presenting with dysphagia symptoms. The most prevalent obstructive aetiologies are oesophageal cancer, peptic strictures and eosinophilic oesophagitis. Eosinophilic oesophagitis is one of the most common causes of dysphagia in adults and children, thus justifying the need to obtain oesophageal biopsy samples from all patients presenting with unexplained dysphagia. With the advent of standardized high-resolution manometry and specific metrics to characterize oesophageal motility, the Chicago classification has become a gold-standard algorithm for manometric diagnosis of oesophageal motor disorders. In addition, sophisticated investigations and analysis methods that combine pressure and impedance measurement are currently in development. In the future, these techniques might be able to detect subtle pressure abnormalities during bolus transport, which could further explain pathophysiology and symptoms. The degree to which novel approaches will help distinguish dysphagia caused by motor abnormalities from functional dysphagia still needs to be determined.

IgG4-Related Esophageal Disease Presenting as Esophagitis Dissecans Superficialis With Chronic Strictures

IgG4-related disease is a recently recognized autoimmune systemic disorder that has been described in various organs. The disease is characterized histologically by a dense lymphoplasmocytic infiltrate of IgG4-positive cells, storiform fibrosis and can be associated with tumefactive lesions. IgG4-related disease involving the upper gastrointestinal tract is rare and only two previous case reports have reported IgG4-related esophageal disease. We report the case of a 63-year-old female patient with a long-standing history of severe dysphagia and odynophagia with an initial diagnosis of reflux esophagitis. Symptoms persisted despite anti-acid therapy and control esophagogastroduodenoscopy (EGD) revealed endoscopic images consistent with esophagitis dissecans superficialis (sloughing esophagitis). An underlying autoimmune process was suspected and immunosuppressant agents were tried to control her disease. The patient eventually developed disabling dysphagia secondary to multiple chronic esophageal strictures. A diagnosis of IgG4-related disease was eventually made after reviewing esophageal biopsies and performing an immunohistochemical study with an anti-IgG4 antibody. Treatment attempts with corticosteroids and rituximab was not associated with a significant improvement of the symptoms of dysphagia and odynophagia, possibly because of the chronic nature of the disease associated with a high fibrotic component. Our case report describes this unique case of IgG4-related esophageal disease presenting as chronic esophagitis dissecans with strictures. We also briefly review the main histopathological features and treatment options in IgG4-related disease.

Lichen planus is an uncommon cause of nonspecific proximal esophageal inflammation

Background/Aims

Esophageal lichen planus (LP) has been described as a cause of nonspecific esophagitis that may cause dysphagia, but its incidence is unknown. We aimed to estimate the incidence of esophageal LP in a defined geographic region and describe the clinical characteristics of affected patients.

Methods

A histopathology database for a population of 1 million people was searched for all esophageal mucosal biopsy results over an 8-year period. Cases showing inflammation or abnormalities without a diagnosis after three or more biopsies were reviewed for findings of LP.

Results

Of 13,589 esophageal biopsies, only one received a diagnosis of LP. Seven patients (four male; mean age, 59 years; range, 39 to 76 years) were identified as having chronic dysphagia and nonspecific proximal esophagitis for which no diagnosis could be made. All patients had proximal inflammation, and six of seven had full-thickness lymphocytic infiltration. Elongation of the lamina propria papillae was noted in all patients, whereas six patients had parakeratosis and ballooning. Only one patient had findings potentially consistent with, but not sufficient for, a diagnosis of esophageal LP.

Conclusions

Esophageal LP appears to be extremely uncommon in this North American population, and esophageal biopsy alone is likely not sufficient to establish a diagnosis of LP.

Sloughing esophagitis is associated with chronic debilitation and medications that injure the esophageal mucosa

Sloughing esophagitis is characterized by superficial necrotic squamous epithelium and endoscopic plaques or membranes. According to abstract reports SE affects older, debilitated patients on multiple medications. This study seeks to evaluate the clinical findings in patients with SE. Thirty-one patients with necrotic superficial squamous epithelium, with endoscopic white plaques or membranes, but without fungi, were compared with 34 patients having esophageal biopsies done for any purpose other than Barrett's surveillance. Sloughing esophagits patients were older than controls (56 vs 43.5 years) and were more likely to be taking five or more medications (77 vs 32%), especially central nervous system depressants (65 vs 32%) and medications associated with esophageal injury (55 vs 18%). In 69% the plaques were in the distal and/or mid-esophagus; 23% involved the entire esophagus; 8% were limited to the proximal esophagus. There was no correlation between medication history and site. Sloughing esophagitis patients were likely to be debilitated based on evidence such as being on home oxygen, in nursing homes, bedridden, hospitalized, or malnourished, having metastatic cancer, organ transplantation, and/or being immunosuppressed. Sloughing esophagitis patients were more likely to have died since the biopsy (23 vs 3%), have peptic ulcer disease (55 vs 24%), or renal insufficiency (16% vs none), but no more likely to have dysmotility disorders, irritable bowel disease, or atherosclerosis. SE patients were less likely to have gastroesophageal reflux disease (45 vs 74%). No specific cause for sloughing esophagitis was identified, but the association with multiple drugs and conditions that may lead to esophageal stasis and/or injury, suggest that this is a local, perhaps contact injury, rather than an ischemic injury.

Esophagitis dissecans superficialis ("sloughing esophagitis"): a clinicopathologic study of 12 cases

Esophagitis dissecans superficialis (EDS) is a term applied to a rare endoscopic finding characterized by sloughing of large fragments of the esophageal squamous mucosa that may be coughed up or vomited. Although EDS has been reported in association with certain medications and esophageal strictures, most cases remain unexplained and the histopathologic features of EDS are inadequately described. We undertook this study to define useful diagnostic criteria based on the examination of a series of well-characterized cases of EDS. To identify patients with EDS, we searched our endoscopy and pathology databases, reviewed the esophageal biopsy specimens from candidate cases, and correlated them with pertinent clinical information. Twelve patients (11 men and 1 woman) had endoscopic and histologic findings of EDS and 9 had the histologic features without the endoscopic correlates. Biopsies from confirmed EDS patients showed sloughing and flaking of superficial squamous epithelium with occasional bullous separation of the layers, parakeratosis, and varying degrees of acute or chronic inflammation. Fungal elements were identified in 3 patients, but were not associated with acute inflammation. None of the EDS patients were on bisphosphonate therapy or had bullous skin disorders. Follow-up endoscopy in 5 patients showed complete resolution of the esophageal abnormalities in 4 and mild esophagitis in one. In spite of its sometimes, dramatic presentation, EDS is a benign condition that resolves without lasting esophageal pathology. Although an association with medications, skin conditions, heavy smoking, and physical trauma has been reported, the pathogenesis of EDS remains unexplained.

Barrett's esophagus and reflux esophagitis: is there a missing link?

OBJECTIVES

Barrett's esophagus (BE) is associated with esophageal reflux. The development stage of BE is not well described. Epidemiological evidence indicates that the columnar epithelium in BE is acquired and reaches its full length rapidly. We tested the hypothesis that BE might result from direct replacement of erosions in reflux esophagitis (RE).

METHODS

At endoscopy, we compared the length and distribution of esophageal erosions in 50 patients with RE with the length and distribution of columnar epithelium in 50 patients with BE.

RESULTS

The median length of erosions in RE was 2 cm, less than the median length of columnar epithelium in BE, 5 cm (p < 0.001). Erosions in RE were usually multiple and scattered, involving the entire circumference of the esophagus in only 10% of cases, but circumferential involvement by columnar epithelium was found in 68% of BE cases (p < 0.001). Circumferential involvement, 3 cm or longer, was found in 0% of cases of RE versus 56% of BE cases (p < 0.001). Two patients without RE or BE had large areas of epithelial loss of uncertain etiology.

CONCLUSIONS

The length and distribution of erosions in RE differ greatly from the length and distribution of columnar epithelium in BE. It is unlikely that BE arises directly from areas of esophagitis. We suggest that BE may develop after loss of a long segment of squamous epithelium, with columnar replacement in the presence of continuing acid reflux.