Histologic Characterization of Esophagitis Dissecans Superficialis
SW Carmack, SJ Spechler, RM Genta. Dallas VA Medical Center, Dallas, TX; Caris Diagnostics, Irving, TX
Background: Esophagitis Dissecans Superficialis (EDS) is a rare entity characterized by shedding of the esophageal mucosa that may be coughed up or vomited. It has been reported in association with bisphosphonate use and strictures, but most cases remain unexplained. Diagnosis rests on the endoscopic detection of mucosal sloughing, often in a clinical setting of prolonged dysphagia. The histologic correlate is inadequately characterized, and in the absence of defined criteria a descriptive diagnosis is often made. We undertook this study in an attempt to define useful diagnostic histologic criteria for the diagnosis of EDS.
Design: We identified cases by searching : 1) endoscopy database for patients with features compatible with EDS; and 2) pathology database for esophageal biopsies with the keywords sloughing and parakeratosis. We then cross-searched for EGD, clinical, and histopathologic information.
Results: The EGD search yielded 8 confirmed cases. The pathology search had 12 putative cases: 5 had compatible EGD findings; 6 had strictures and 1 had plaques. Thus, we had 13 confirmed cases, 12 men and one woman (age 48-82). Presentation included: chronic dysphagia (6 pts), upper GI bleeding not from EDS (5), weight loss (1), and asymptomatic (1). By EGD, all had the characteristic tissue paper appearance of the esophagus; 6 also had esophagitis (4 w/ grade D); 2 had strictures. None were on bisphosphonate therapy or had bullous skin disorders; 3 had prior surgery (Nissen, Billroth). Histologically, all cases showed sloughing and flaking of superficial squamous epithelium with bullous separation of the layers, parakeratosis, and varying degrees of acute or chronic inflammation. Fungi, identified in 3 cases, were not associated with acute inflammation, likely representing contamination. Follow-up EGD after proton-pump inhibitor therapy showed resolution of esophagitis and EDS in all but one patient. The 7 patients without EDS had similar histology, but without superficial bullous separation; 5 had acute inflammation with debris; the other 2 had acanthosis and parakeratosis; none had fungi.
Conclusions: Histologic features of EDS are similar to biopsies taken from esophageal strictures, and may be confused with candidiasis due to contamination of detached squamous fragments. However, superficial bullous separation seems unique to EDS. Nevertheless, close endoscopic correlation is essential to establishing the correct diagnosis. Both etiology and clinical implications of EDS remain unclear, but it seems to respond to acid-inhibition therapy.
Wednesday, March 11, 2009 1:00 PM
Poster Session VI # 84, Wednesday Afternoon