E. FIANI (1), F. GUISSET (1), Q. FONTANGES (2), J. DEVIERE (1), A. LEMMERS (1) / [1] Erasme Hospital, Brussels, Belgium, (1) Gastroenterology, Hepatopancreatology and Digestive Oncology department, [2] Erasme Hospital, Brussels, Belgium, (2) Pathology department
Introduction: Esophagitis dissecans superficialis (EDS) is a rare desquamative disorder of the esophagus, characterized by sloughing of the superficial mucosa. It is a benign entity of uncertain etiology. Most cases of EDS are idiopathic but can be caused by medications, hot beverages, chemical irritants, celiac disease and many skin conditions.
Aim: Knowing that few case series have described this entity, we decided to review all the cases diagnosed in our center to characterize them.
Methods: The pathological institutional database of Erasme University Hospital (Brussels, Belgium) was searched for the diagnosis of EDS. We reviewed retrospectively the clinical and endoscopic findings as well as histological features of all cases of EDS (table 1). During this period of time, 21500 upper gastrointestinal endoscopies have been performed in our institution.
Results: From 2010 to 2016, we identified 7 cases of EDS diagnosed in our institution in this time period. During the same period, 21500 upper gastrointestinal endoscopies were performed (incidence 0.03%). The median age of presentation was 73 years old, with a female predominance (85%). Associated symptoms were variable from weight loss and nausea to epigastric pain, dysphagia and atypical chest pain. The most common co-morbidity found was treated hypertension in 3 patients. There were no skin diseases in any of these patients. Only one patient in our series had an identified potential causal factor (clindamycin), because of the sudden onset of symptoms upon initiating clindamycin for septic arthritis. Endoscopic findings evoked in 2 patients a suspicion of an esophageal tumor; the first one was described as a raised detached lesion of the distal third of the esophagus with suspicion of squamous cell carcinoma (Figure 1) and the second as a suspected tumor of the proximal third of the esophagus (Figure 2). For other patients, EDS was misdiagnosed as unspecific esophagitis in 3, reflux or mycotic esophagitis in 2. Only one patient was suspected to have sloughing esophagitis. Histologic features present in all of those cases were characterized by the presence of a sloughing and necrosis of the superficial layer of the esophageal squamous epithelium with negative anti HSV and anti CMV antibodies, negative periodic acid Schiff stain for fungal infections as well as absence of signs of dysplasia or signs of malignancy. In 2 patients, there was a presence of multiple bacterial colonies on the superficial epithelium. Acute inflammation was reported in 4 of the patients with the presence of eosinophils in the superficial epithelium described in 2 of these patients and of polymorphonuclear leukocytes in 2 other patients (figure 3). An endoscopic follow up 2 months after PPI treatment (with pantoprazole 40 mg once daily) was performed in 2 patients who had an atypical endoscopic presentation with suspicion of a previous suspicion of esophageal neoplasia. A complete healing of the esophageal lesions was observed in these 2 patients (Figure:4).
Conclusions: EDS is a rare benign entity that endoscopists must be aware of in order not to mistake it for other entities such as esophagitis or squamous cell carcinoma. The diagnosis is based on biopsies. The prognosis is good after stopping the causative agent and with PPI treatment.