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A 76-year-old woman, an ex-smoker, presented with several months' history of gastroesophageal reflux disease (GERD), recent weight loss, and a 1-week-old history of lower gastrointestinal bleeding. Her symptoms of heartburn were persisting despite her daily intake of omeprazole 40 mg daily. There was no associated dysphagia to solids or liquids. She also had a known history of internal hemorrhoids. Her lab tests showed a hemoglobin of 12.2 g/dL and a hematocrit of 37.8. An upper gastrointestinal endoscopy and a colonoscopy were done. Endoscopy showed multiple large white plaques in the lower esophagus, while the colonoscopy confirmed internal hemorrhoids in her lower rectum. Esophageal biopsies taken during endoscopy revealed an undulating esophageal squamous mucosa with a compact surface hyperorthokeratosis and a prominent underlying granular cell layer. An abrupt transition was noted between the area of epidermoid metaplasia and adjacent uninvolved normal squamous mucosa. PAS stain was negative for fungal organisms. There was no evidence of any dysplasia or carcinoma. A diagnosis of esophageal epidermoid metaplasia or esophageal leukoplakia was given. Esophageal leukoplakia is a rare histological counterpart of oral leukoplakia occurring in mostly middle-aged women. The most common complaint is dysphagia although few others may present with GERD symptoms (as in our patient) or achalasia. Significant risk factors that are similar to those in oral leukoplakia include smoking and alcohol consumption. The usual endoscopic appearance is that of white patches of plaque-like mucosa. Because of the reported high rate of squamous dysplasia or rarely even squamous cell carcinoma in the adjacent esophageal mucosa, these patients need close endoscopic follow-up. Also endoscopic screening should focus not only on the area of leukoplakia but also adjacent mucosa to pick up early dysplasia and/or cancer.

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