1825 Esophageal Stricture Due to Esophageal Lichen Planus and Its Successful Management Using Local Corticosteroid Injection

Abstract

INTRODUCTION: Lichen planus is an inflammatory disease that typically involves the skin, nails, oral cavity and the genital areas. Involvement of the esophagus is rare. We report a case with severe progressive esophageal lichen planus treated with submucosal injection of triamcinolone into the esophagus with symptomatic improvement and decreased need for esophageal dilation. CASE DESCRIPTION/METHODS: A 64-year-old Caucasian female presented to the GI clinic for evaluation of progressive dysphagia of 1 year. She has been doing well until she had a severe choking episode while swallowing a tablet. Physical examination revealed red, atrophic plaques on the buccal mucosa as well as vaginal erythema and atrophy. Tongue biopsy was performed which showed lichenoid inflammation with dermatitis and spongiosis consistent with the diagnosis of lichen planus (Oral-Gingival-Vaginal syndrome). The patient was started on 75mg of prednisone for 1 month followed by a slow taper. A barium swallow showed a short, smoothly marginated stricture of the proximal esophagus at the C6-C7 level with approximately 75% narrowing. EGD showed a stricture in the proximal esophagus at 18cm. Remaining upper and mid esophagus showed multiple lesions with peeling of mucosa and areas of mucosal hemorrhage. Biopsies of the stricture showed small fragments of squamous mucosa with lymphocytic infiltrate and necrotic keratinocytes (Civatte bodies). Esophageal bougie dilations were performed for management of dysphagia. As the upper stricture required repeated dilations [every 1-2 months] and other management options were either ineffective or not tolerated, local sub mucosal corticosteroid injection (Kenalog-40) into the proximal stricture was attempted along with esophageal dilations. This resulted in decrease the average frequency of dilations and ultimately she became symptom free since except for occasional pain with swallowing food and intermittent esophageal spasms. DISCUSSION: The diagnosis of esophageal lichen planus is often difficult. However, this disease should be suspected amongst middle age to older women presenting with progressive dysphagia. Treatment with systemic corticosteroids remains the mainstay of treatment in esophageal lichen planus. However, in those unable to tolerate steroids due to side effects, non-responsive progressive disease or individuals who are experience frequent relapses after discontinuation of systemic steroids, corticosteroid injection is a safe and effective alternative therapy.