LAUSR

A 45-year-old Caucasian woman presented with a two-day history of anorexia, nausea, vomiting, and severe gastro-esophageal reflux symptoms but denied melena or hematemesis. She developed coffee-ground vomiting and dysphagia the following day and was unable to tolerate any oral intake. Her past medical history includes decompensated liver cirrhosis secondary to previous alcohol abuse and esophageal variceal bleed requiring endoscopic variceal ligation. She had a very recent protracted hospital admission with septic shock secondary to spontaneous bacterial peritonitis and required prolonged admission in intensive care unit with inotropic support. The new-onset dysphagia was investigated with an endoscopy, and the endoscopic appearance (Fig. 1) was consistent with a diagnosis of esophagitis dissecans superficialis (EDS). This was characterized by confluent, circumferential esophagitis (Fig. 1a), sloughed esophageal “cast” (black arrow in Fig. 1b), and longitudinal ridges throughout the esophagus. She had a normal appearing gastro-esophageal junction and gastric mucosal folds (Fig. 1c). Biopsies were not performed as the patient was coagulopathic and had underlying small esophageal varices. She was treated with high dose intravenous pantoprazole and was maintained on a clear fluid diet for 2 days with gradual upgrade to a soft diet. She was subsequently discharged with oral pantoprazole therapy for 6 weeks. Follow-up endoscopy 6 weeks later revealed mucosal healing and a completely normal esophagus (Fig. 2). Esophagitis dissecans superficialis is an uncommon endoscopic finding in patients presenting with dysphagia and reflux symptoms. EDS can be asymptomatic, but patients predominantly present with dysphagia, odynophagia, and gastro-esophageal reflux symptoms. In some instances, patientsmay even report vomiting casts of esophageal mucosa. The classic endoscopic finding of EDS is sloughed esophageal “cast.” Longitudinal or circumferential cracks and rings may also be viewed on endoscopy. Candida esophagitis might have similar endoscopic findings resulting in misdiagnosis. Histologically, biopsies from EDS patients often demonstrate sloughing of superficial squamous epithelium with intermittent bullous separation of the layers. Pathogenesis of EDS is still unclear. However, some associated risk factors include the following: