August 2015 Case of the Month
84 year-old man with dysphagia undergoing upper endoscopy. Per endoscopy report, "esophageal mucosa easily sloughs off".
Low power view reveals esophageal squamous mucosa with a two-tone appearance. The superficial mucosa shows a sharply demarcated eosinophilic layer. The eosinophilic layer is partly sloughed.
The superficial eosinophilic layer shows parakeratosis. A small fragment of mummified/necrotic epithelium is also present. No active inflammation, viral inclusions, or fungal elements are apparent.
Sharp delineation between parakeratotic superficial mucosa and underlying normal appearing mucosa.
Low power view reveals esophageal squamous mucosa with a two-tone appearance. The superficial mucosa shows a sharply demarcated eosinophilic layer. The eosinophilic layer is partly sloughed.
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The esophageal biopsy shows a striking demarcation between a brightly eosinophilic superficial parakeratotic layer and the underlying more normal appearing squamous mucosa. The parakeratotic layer is partly sloughed in some fragments. In addition, frequent detached squamous keratin flakes and necrotic/mummified mucosal fragments are present in the background. Frequent bacterial colonies are associated with the sloughed mucosa. Importantly, there is no evidence of viral inclusions, eosinophilic esophagitis, significant active inflammation, and a PAS stain is negative for fungal organisms. These features and the clinical endoscopic description of sloughing mucosa are consistent with esophagitis dissecans superficialis (EDS). While not entirely understood, EDS has been associated with chronic debilitation, thermal and chemical (pill) injury (NSAIDs, CNS depressants, bisphosphonates), heavy smoking, and trauma. Most cases resolve spontaneously without lasting esophageal pathology.