1717 “Dissec-ting” the Etiology

Abstract

INTRODUCTION: Esophagitis dissecans superficialis (EDS) was first described in 1892. It is a rare and benign desquamative disorder characterized by sloughing of the esophageal mucosa. EDS has been linked to coronary artery disease, chronic kidney disease, autoimmune conditions (celiac disease and pemphigus vulgaris) and medications known to damage the gastrointestinal tract. However, most cases are idiopathic. CASE DESCRIPTION/METHODS: A 48-year-old male with a PMH of GERD presented to the Gastroenterology clinic with a 6-month history of esophageal dysphagia to solid foods. He denies any nausea, vomit, abdominal pain, hematemesis or episodes of melena. Esophagogram revealed delay of the barium tablet (Figure 1). The patient underwent an EGD showing sloughing of the mucosa in the entire esophagus along with LA grade C esophagitis (Figure 2). Biopsies were taken from the proximal and distal esophagus with findings compatible with esophagitis dissecans superficialis (Figure 3). Ranitidine and PPI were continued and he was scheduled for a follow appointment in 6 weeks. DISCUSSION: EDS is typically seen in middle aged women, and is commonly misdiagnosed due to the lack of diagnostic or histologic criteria. Endoscopic features consist of esophageal mucosa with multiple columns of strips that have whitish/pearly appearance andsloughs which are > 2 cm in length, and lack of ulcers in the surrounding mucosa. These findings can be mistaken with esophageal candidiasis, eosinophilic esophagitis, lichen planus and even squamous cell carcinoma. For this reason, the diagnosis is made through histopathologic findings such as parakeratosis and intraepithelial splitting above the basal layer. As in our patient, dysphagia is frequently reported, but nonspecific symptoms like nausea, vomiting or heartburn are also found. There are no specific treatment guidelines. Nevertheless, acid suppressants can be started to aid mucosa healing. Some patients can present with esophageal strictures, but this entity mainly follows a benign course as it shows self-resolution from 8 weeks to 4 months of diagnosis. This case shows the importance of recognizing EDS not only as an underreported cause for dysphagia, but also as an important differential diagnosis for esophageal diseases. It is important to obtain mucosal biopsies in order to get a proper diagnosis and avoid unnecessary treatments.