Diagnosis

Diagnosis 

Sloughing esophagitis.

Discussion

Endoscopically, sloughing esophagitis will typically present with white exudates or plaques in the mid and/or distal esophagus with or without erosions or webs. Histologically there is a characteristic ‘two-toned’ appearance; while the basal epithelium is relatively unremarkable, there is a superficial zone of eosinophilic necrosis which is separated from the normal epithelium by a band of neutrophils. On high power examination, the nuclei of this superficial eosinophilic layer may be pyknotic nuclei or have a faded or ‘ghost-like’ appearance. A fungal esophagitis should be excluded before rendering the diagnosis of sloughing esophagitis.

Clinically, sloughing esophagitis is equally common in both males and females, although it is more typically encountered in middle age patients. Approximate 50% of patients will present with esophageal symptoms including dysphagia and heartburn. As well, approximate half of the patients with sloughing esophagitis are immunosuppressed. As detailed by Purdy et al., the majority (77%) of patients with sloughing esophagitis are taking five or more prescription medications.

Beyond sloughing esophagitis, the histologic differential diagnosis for superficial epithelial necrosis includes candidiasis, pill esophagitis, corrosive agents, and esophagitis dissecans superficialis (which by some is equated to being the same as sloughing esophagitis). Candidiasis is a common cause of endoscopically observable white esophageal plaques. Special staining, including GMS, may assist with highlighting pseudohyphal and/or yeast forms in the superficial squamous epithelium.

Pill esophagitis may occur with certain medications, especially those that are direct irritants, such as doxycycline or quinidine; correlation with the patient’s medication history is recommended. Corrosive agents may demonstrate white plaques endoscopically, as well as edema and hemorrhage; in these cases it would be expected that there is necrosis and marked inflammation of at least the superficial squamous epithelium, although it may extend deeper and result in perforation. Acute esophageal necrosis is a rare entity which endoscopically will present with patchy pigmentation of the esophagus (so-called ‘black esophagus’) initially, while later developing into a thick white exudate with necrotic debris over an ulcer; with this diagnosis, acute inflammation and necrosis will frequently extend into the submucosa.
 

References

• Purdy JK, Appelman HD, McKenna BJ. Sloughing esophagitis is associated with chronic debilitation and medications that injure the esophageal mucosa. Mod Pathol. 2012;25, 767-775.

• Moore RJ, Lazenby AJ, Wilcox CM. Sloughing esophagitis: a distinct histologic and endoscopic entity. Mod Pathol. 1999;12:81A.

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