Diagnosis & Discussion

Diagnosis

Sloughing esophagitis

Discussion

Sloughing esophagitis (SE), also known as esophagitis dissecans superficialis, is a condition of necrosis and shedding of the superficial layer of the esophageal epithelium. It is a rare, albeit underreported entity. Patients with SE are often elderly and debilitated with multiple co-morbidities. Presenting symptoms include heartburn, dysphagia, and regurgitation. SE may also be an incidental finding in younger, asymptomatic patients undergoing evaluation for unrelated conditions.

On endoscopy, the shed epithelium appears as white plaques, streaks, or patches along the entire length of the esophagus or over a more limited surface area (Fig. 1-3). On microscopy, the esophageal epithelium has a dual-tone appearance with a superficial layer of necrotic deeply eosinophilic squamous cells overlying a deep layer of viable epithelium (Fig. 4-6), separated on occasion by a band of necrotic, spongiotic squamous cells and neutrophils (Fig. 6).

The cause of SE is unknown. There is an association between SE and the simultaneous use of multiple medications (polypharmacy). Drugs that cause direct epithelial injury (e.g., iron, non-steroidal anti-inflammatory drugs, and potassium) have been implicated, thus leading to the postulation that SE may be due to contact injury. One study also showed an association between SE and psychoactive drugs. Rarely, SE is associated with immunobullous dermatoses like bullous pemphigoid and pemphigus vulgaris. This has given rise to speculation that, at least in some cases, defects in cell adhesion may underlie SE.

Eosinophilic esophagitis and Candida esophagitis may have a similar clinical presentation and endoscopic appearance. But they are easily distinguished on microscopy by the presence of increased intraepithelial eosinophils or invasive fungi, respectively. Of note, fungal organisms may also be seen in SE, but they are noninvasive bystander contaminants.

SE per se is a benign, often self-limiting condition. It also responds well to the stoppage of offending medications or treatment of any associated dermatologic condition. However, increased mortality has been reported in patients with SE, but attributed to the effects of preexisting debilitating conditions.

References

Hokama A, Yamamoto Y, Taira K, et al. Esophagitis dissecans superficialis and autoimmune bullous dermatoses: a review. World J. Gastrointest. Endosc. 2010; 2:252-256.

Moawad F, Appleman HD. Sloughing esophagitis: a spectacular histologic and endoscopic disease without a uniform clinical correlation. Ann. N.Y. Acad. Sci. 1380 (2016) 178–182 C2016 New York Academy of Sciences.

Purdy, J.K., H.D. Appelman & B.J. McKenna. Sloughing esophagitis is associated with chronic debilitation and medications that injure the esophageal mucosa. Mod. Pathol. 2012. 25: 767–775

Polydorides AD, Purdy JK. Sloughing esophagitis in Greenson J K, Lauwers GY, Montgomery EA, Owens SR, et al. (editors). Diagnostic Pathology: Gastrointestinal. Elsevier, Philadelphia, 2016.

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