Lichen Planus: Esophageal Involvement

Abstract

Case Presentation: A 71-year-old white female with a past medical history of gastroesophageal reflux disease presented with intermittent dysphagia to solid food and odynophagia that had been progressing for the past few months. She also reported unintentional weight loss. Patient has history of erosive lichen planus that was causing ulcers in her oropharynx three years ago and it was treated with topical steroids. All her initial laboratory tests were normal, this includes CBC, BAMP, LFTs. Barium sallow was performed and showed narrowing in the proximal one-third of the esophagus. Subsequent upper endoscopy revealed ulcerated circumferential stricture in the proximal esophagus just 2 cm below the cricopharyngeal muscle. Upper endoscopy also showed moderate mid and distal esophageal strictures (Figure. 1). Esophageal biopsies were consistent with acute erosive esophagitis with lymphocytic predominance and with minimal eosinophils. Based on the presence of oral lichen planus, our patient's endoscopic apperance and the biopsy findings, the patient was diagnosed with esophageal lichen planus. She had undergone multiple esophageal dilatations since the initial presentation. She had also received a course of systemic steroids. On follow-up, the patient was clinically stable and had denied worsening of her symptoms.Figure 1Discussion: Lichen planus is a common idiopathic disorder involving skin, nail, and mucosal membranes. It is characterized by immune response attacking an antigen in the basal cells of squamous epithelium. Esophageal lichen planus is a relatively rare condition and the prevalence is unknown. The diagnosis can be challenging due to the subtle clinical findings and lack of characteristic histologic features. Esophageal lichen planus usually affects the upper and mid esophagus; in addition, it often spares the gastroesophageal junction when compared to reflux esophagitis. The history of oral lichen planus, endoscopic images and site of esophageal involvement are very helpful in differentiating between the latter two entities. Esophageal lichen planus has a tendency to be chronic disease with the potential risk of malignancy. Topical and oral steroids are the mainstay of treatment but to date there are no wellestablished guidelines. Conclusions: Oropharyngeal lichen planus is a chronic disease that can lead to recurrent esophageal stricture. Endoscopic findings and pathology may not be specific; however, clinicians should be aware of this entity and appropriate referrals should be made as patients might need repeated interventions to have a relief in their symptoms.