An eighty one year old female was evaluated for progressive, intermittent solid food dysphagia for eight years. She had been managed previously with a daily dose of a proton pump inhibitor with minimal response. She had no heartburn, regurgitation, nausea, emesis, food impaction, altered bowel pattern, gastrointestinal bleeding or weight loss. Her past medical history was significant for psoriasis, seasonal allergies and hypothyroidism. She reported no family history of gastrointestinal disorders. She was a former smoker with a thirty pack year history and reported alcohol use socially.
Physical examination was notable for a woman with a normal body mass index in no acute distress. Vital signs were within normal limits. Her abdomen was soft, non-tender and non-distended on palpation without evidence of hepatosplenomegaly. Bowel sounds were normal. Pertinent negatives include a normal skin and oral examination.
Normal oro-pharyngeal swallowing physiology was noted for all consistencies on a modified barium swallow examination. A barium esophagogram demonstrated a limited distensibility of esophagus with impaired passage of the administered barium pill. (Figure A) High resolution esophageal manometry was normal with 100% peristalsis and a normal IRP of 1.3 mm of Hg. An upper endoscopy showed a severe esophageal stenosis along the entire length of the esophagus measuring approximately 10 mm in diameter with moderate resistance to passage of an adult gastroscope. (Figure B). Esophageal biopsies are as shown in Figure C.
Endoscopic biopsies of the esophagus demonstrate esophageal mucosa with interface inflammatory infiltrate (predominantly lymphocytes) that obscures the squamous mucosa and submucosal junction. Scattered apoptotic keratocytes are noted. Consider lichenoid mucositis with reflux esophagitis (Figure 3)
Lichen planus is an idiopathic inflammatory disorder that involves mucocutaneous tissues , namely the skin, nails, hair and genitalia. Esophageal lichen planus (ELP) is rare, particularly in the absence of oral involvement. It has been reported most commonly among middle aged women who present with symptoms of dysphagia, odynophagia or a food impaction. Endoscopic evaluation often demonstrates a narrow caliber esophagus or a long esophageal stricture predominantly involving the proximal esophagus as well as esophageal erosions, ulcers and friable or desquamative mucosa in severe cases.