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Clinical presentation
A 62-year-old female patient with a history of gastric bypass surgery (Roux-en-Y) was seen in the surgical outpatient clinic complaining of epigastric pain, heartburn and mild dysphagia. The current symptoms had started 2 months before the presentation and were increased by hot food and beverages. The patient reported no weight loss or other B symptoms. The patient’s medication included trimipramine and several food supplements. Laboratory testing revealed no abnormal results. High-resolution manometry and 24 hours impedance pH measurement were normal. We performed an oesophagogastroduodenoscopy, which revealed shedding of the mucosa along the whole length of the oesophagus, consistent with desquamation (figure 1A–C). The remaining stomach was short (7 cm), the rest of the endoscopy was normal. Biopsies were taken from the proximal and distal oesophagus (figure 2) and histopathology was reported as squamous epithelial lamellae with partial splitting of the epithelium together with acute and chronic inflammation. Microbiology studies excluded viral (cytomegalovirus, Herpes simplex virus) and fungal infection.
Representative endoscopic images in upper (A), mid (B) and lower (C) oesophagus.
Splitting of the squamous epithelium above the basal layer on H&E stain (scale bar 100 µm).
Question
What is the diagnosis? How can the patient be treated?
Answer
Findings are consistent with sloughing oesophagitis or oesophagitis dissecans superficialis (EDS). EDS is a rare benign illness, which endoscopists should be aware of in order not to mistake it with other entities. Endoscopically, EDS is characterised by long, vertical white strips of peeling mucosa with underlying intact oesophageal lining. The endoscopic appearance of EDS has been likened to lizards shedding their skin.1 EDS can be associated with oesophageal strictures. Although the precise pathogenesis remains unexplained and the histopathological features are inadequately described, an association of EDS with caustic or hot beverage ingestion, autoimmune bullous dermatosis (eg, pemphigus vulgaris), and drugs such as potassium chloride, non-steroidal anti-inflammatory drugs, bisphosphonates, benzodiazepines and antidepressants has been reported.2 EDS is typically asymptomatic, however, occasional symptoms may be dysphagia, odynophagia, nausea and vomiting, heartburn or bleeding.3 Patients may report vomiting tubular casts of oesophageal mucosa. The natural course of EDS is benign with a good prognosis and it typically resolves completely after treatment with proton pump inhibitors (PPI).
The reported patient responded well to high-dose PPI treatment with alleviation of the reported symptoms. An endoscopic follow-up examination was performed 5 month later and showed improvement of findings (figure 3). The patient relapsed 4 months after the follow-up study while still under PPI therapy, but improved again after switching from pantoprazole to esomeprazole.
Regressive endoscopic finding after 5 months of PPI therapy. PPI, proton pump inhibitor.
Ethics statements
Patient consent for publication
Footnotes
Twitter @niklaskrupka
Contributors RS and NK wrote and designed the manuscript and figures; RS and MB performed the endoscopies; HD performed the histological studies; MB coordinated the diagnostic and therapeutic steps.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
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