P1409 - Esophagitis Dissecans Superficialis: A Rare but Frequently Missed Diagnosis

Godson D. Senyondo, MD¹, Ali Khan, MD¹, Fahad Malik, MD¹, Siya Bhagat, MS², Ali Timsar, MD¹, Amanke Oranu, MD^1
1UHS Wilson Hospital, Johnson City, NY; ²Upstate Medical University, Syracuse, NY

Introduction: Esophagitis dissecans superficialis (EDS) is a rare, benign condition characterized by esophageal mucosal sloughing. EDS is frequently found among elderly, chronically debilitated patients who are on multiple medications. The etiology of EDS is currently unclear; while some cases are idiopathic, others are linked to irritants, medications and bullous skin conditions. We report a case of EDS in a patient on chronic oral NSAIDs.

Case Description/Methods: A 54-year old male presented with a 3 week history of sharp non-radiating epigastric pain, nausea, and non-bloody vomiting which worsened over the last 4 days. He also reported poor appetite, inability to keep food down, and an unintentional 20 pound weight loss. He reported no diarrhea, melena, hematochezia, dysphagia, odynophagia, chest pain, or dyspnea. Pertinent medical history included tobacco smoking, chronic arthritis treated with oral diclofenac, depression treated with citalopram and prophylactic Truvada use. Initial vital signs were stable. Physical examination revealed moderate epigastric tenderness. Notable labs included a BUN of 185 mg/dl, Cr of 34.5 mg/dl, lipase of 1323 U/l, and normal CBC, hepatic panel, and lactate. A non-contrast CT abdomen and pelvis was unrevealing. Given his persistent symptoms and long term NSAID use, there was a concern for PUD. An upper gastrointestinal endoscopy (EGD) revealed a 2 cm hiatal hernia with esophageal mucosal sclerosis, gastritis, and congested duodenal mucosa (Figure 1). A distal esophageal biopsy confirmed EDS (Figure 2). The patient’s diclofenac was discontinued and he was treated with oral sucralfate and high dose pantoprazole with complete resolution of symptoms.

Discussion: EDS is a rare endoscopic-histological finding characterized by sloughing of superficial strips of squamous mucosa. Histology shows splitting of the epithelial layers by occasional bullous separations, parakeratosis, and minimal inflammation. While some patients remain asymptomatic, others experience dysphagia, abdominal pain, nausea, and vomiting. EDS may be underreported as biopsies are commonly contaminated with bacteria and fungi, leading to frequent misdiagnosis. It is thus important to consider EDS as a differential diagnosis during interpretation of both endoscopic and pathology findings. In our case, his cause of EDS may be linked with chronic NSAID use. Given the paucity of cases, management is not well defined but most patients respond well to risk factor modification and PPI therapy.


Figure: a) Endoscopy image showing esophageal mucosal sclerosis. b) Histopathology section showing splitting of the squamous epithelium, a thick layer of parakeratosis at the surface, mild basal cell hyperplasia, and a mild intraepithelial inflammatory infiltrate composed predominantly of neutrophils.


Disclosures:
Godson Senyondo indicated no relevant financial relationships.
Ali Khan indicated no relevant financial relationships.
Fahad Malik indicated no relevant financial relationships.
Siya Bhagat indicated no relevant financial relationships.
Ali Timsar indicated no relevant financial relationships.
Amanke Oranu indicated no relevant financial relationships.


Godson D. Senyondo, MD¹, Ali Khan, MD¹, Fahad Malik, MD¹, Siya Bhagat, MS², Ali Timsar, MD¹, Amanke Oranu, MD¹. P1409 - Esophagitis Dissecans Superficialis: A Rare but Frequently Missed Diagnosis, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.