Esophageal Lichen Planus Research Articles

Esophageal Lichen Planus: The Efficacy and Safety of Tacrolimus in Reducing Inflammation and Need for Dilation.

Esophageal Lichen Planus (ELP) is a rare inflammatory disease most seen in middle-aged Caucasian women, manifested by sloughing mucosa, thick exudate, and proximal strictures. Most case reports and small series highlight using steroids and other immunosuppressants. To our knowledge, oral tablet tacrolimus has not been studied. We aimed to assess the change in ELP after oral tacrolimus treatment. The primary outcome was the efficacy of tacrolimus objectively through our scoring system, ELPSS. All consecutive adults with ELP who underwent more than one EGD by two esophagologists and being treated with tacrolimus or other treatment were eligible for inclusion in this retrospective cohort study. Inflammation and fibrostenotic disease were graded using the novel ELP Severity Score (ELPSS). Twenty two patients met the inclusion criteria. Half (11) received tacrolimus (dose 1-2 mg BID) and half (11) received other therapy (i.e. cyclosporine, topical steroids, or none). Mean ELPSS on first EGD, extraesophageal manifestations of disease, presenting symptoms, and baseline characteristics were similar between groups. Among patients on Tac vs No-Tac, there was a statistically significant improvement in ELPSS (mean difference 1.8 pts; 95% CI 0.25-3.38; P=0.02). Response rate was 89% with Tac vs 30% with No-Tac (P=0.025). All 22 patients underwent bougie dilation safely with a mean diameter of 16 mm achieved. Patients on Tac also required less frequent dilation. Oral tablet tacrolimus reduced the inflammatory and fibrostenotic components of ELP. Thus, low-dose oral tacrolimus is safe and should be considered in patients with more severe disease.

Esophageal Lichen Planus: A Descriptive Multicenter Report.

To better understand the characteristics, treatment approaches, and outcomes of patients with esophageal lichen planus (ELP). ELP is a rare, often unrecognized and misdiagnosed disorder. Data on this unique patient population are currently limited to small, single-center series. A multicenter, retrospective descriptive study was conducted of adults diagnosed with ELP over a 5-year period, between January 1, 2015, and October 10, 2020, from 7 centers across the United States. Seventy-eight patients (average age 65y, 86% female, 90% Caucasian) were included. Over half had at least 1 extraesophageal manifestation. Esophageal strictures (54%) and abnormal mucosa (50%) were frequent endoscopic findings, with the proximal esophagus the most common site of stricture. Approximately 20% had normal endoscopic findings. Topical steroids (64%) and/or proton pump inhibitors (74%) dominated management; endoscopic response favored steroids (43% vs. 29% respectively). Almost half of the patients required switching treatment modalities during the study period. Adjunctive therapies varied significantly between centers. Given its at times subtle clinical and endoscopic signs, a high index of suspicion and biopsy will improve ELP diagnosis, especially in those with extraesophageal manifestations. Effective therapies are lacking and vary significantly. Prospective investigations into optimal treatment regimens are necessary.

Esophageal Lichen Planus as a Cause of Dysphagia: Literature Review and Clinical Observation

Aim: to analyze the literature data, and to raise awareness of doctors of various specialties about the methods of diagnosis and treatment of esophageal lichen planus (ELP).Key points. In a 67-year-old female patient with complaints of difficulty swallowing solid food and weight loss, esophagogastroduodenoscopy revealed subcompensated stenosis of the middle third of the esophagus and signs of fibrinous esophagitis. Based on the characteristics of the endoscopic picture and the detection of apoptotic Ciwatt bodies in esophageal biopsies, a diagnosis of ELP was established. Treatment with glucocorticosteroids led to relief of symptoms and positive endoscopic dynamics. ELP is rare and the least studied, data on this disease in the literature are presented mainly in the form of clinical observations and analysis of series of cases. Typical clinical manifestations include dysphagia and odynophagia. Despite the low prevalence, ELP can be associated with serious complications: stenosis and esophageal squamous cell carcinoma. Endoscopic examination reveals characteristic signs in the esophagus: swelling, thickening and increased vulnerability of the mucosa, often with fibrin, formation of membranes and strictures. The histological picture is represented by epithelial dyskeratosis with exfoliation, lichenoid lymphocytic infiltration. The most specific histological sign is the presence of apoptotic Civatte bodies. Recommendations for the treatment of ELP are limited to the results of a series of clinical observations and include the prescription of systemic corticosteroids. The issue of supportive therapy is the least studied.Conclusion. Analysis of the literature data and the clinical case demonstrate that lichen planus of the esophagus is one of the rare causes of dysphagia. Characteristic endoscopic and histological signs are key for the diagnosis. The management of patients with esophageal lichen planus is insufficiently defined and today includes taking of glucocorticosteroids, endoscopic dilation of stricture and dynamic endoscopic observation, given the high risk of squamous cell carcinoma in this category of patients.

Lichen planus esophagitis.

Dysphagia is one of the most common reasons for patients' visits to a gastroenterologist. Esophageal lichen planus (ELP) has historically been felt to be a rare disease, when in fact it is often misdiagnosed and unrecognized. Often first diagnosed as an unusual esophagitis, all gastroenterologists will see ELP in their practice, and need to be able to recognize this condition. Although there is still a relative paucity of data on this condition, this article will update the typical presenting symptoms, endoscopic findings, and ways to differentiate ELP from other inflammatory mucosal diseases. There is still no standardized treatment algorithm, but we will also present the most recent treatment approaches. It is critical that physicians maintain an increased awareness of ELP and have a high clinical suspicion in the appropriate patients. While management remains challenging, it is important to treat both the inflammatory and stricturing components of the disease. A multidisciplinary approach is also often required, utilizing dermatologists, gynecologists, and dentists who are familiar with managing patients with LP.

Lichen Planus

HomeRadioGraphicsVol. 43, No. 4 PreviousNext Cases from the Cooky JarFree AccessLichen PlanusEdward McDermott , Nadia Solomon, Annelise M. Silva, Parisa KhoshpouriEdward McDermott , Nadia Solomon, Annelise M. Silva, Parisa KhoshpouriAuthor AffiliationsFrom the Department of Radiology, Mater Misericordiae University Hospital, Eccles Street, Dublin D07 R2WY, Ireland (E.M.); Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Conn (N.S.); Department of Education, Wright State University Boonshoft School of Medicine, Dayton, Ohio (A.M.S.); and Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Medical Institution, Baltimore, Md (P.K.).Address correspondence to E.M. (email: [email protected], @edwardmcd).Edward McDermott Nadia SolomonAnnelise M. SilvaParisa KhoshpouriPublished Online:Mar 16 2023https://doi.org/10.1148/rg.220200MoreSectionsPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In Lichen planus is a chronic condition that predominantly affects middle-aged and older women and represents an autoimmune T-cell–mediated inflammatory disorder (Fig 1) that affects the skin, oral and genital mucosa, esophagus, hair, and nails (1). Cutaneous involvement manifests with flat violaceous papules, and mucosal manifestations typically manifest with white lacelike lesions, papules, erythematous lesions, and erosions (Fig 2) (2). Esophageal lichen planus has been reported in more than 50% of patients with mucocutaneous lichen planus and is underrecognized and underreported (2).Figure 1. Esophageal lichen planus. There are limited studies of the pathogenesis of esophageal lichen planus, but it appears to be mediated by cytotoxic CD8-positive T cells. Biopsy of affected esophageal tissue shows keratinization with inflammatory cell infiltration of the epithelium with activated T lymphocytes (6).Figure 1.Download as PowerPointOpen in Image Viewer Figure 2. Mucosal manifestations of lichen planus in a 73-year-old woman who presented with solid food dysphagia. (A) Photograph shows white plaquelike lesions on the tongue. (B) Endoscopic image demonstrates erythema and white papules (arrows).Figure 2.Download as PowerPointOpen in Image Viewer Barium esophagography is the most relevant imaging study to evaluate esophageal lichen planus. Imaging features include a smooth small-caliber esophagus with cervical esophageal webs, strictures, and pseudodiverticula (Fig 3) (3,4). Strictures most commonly occur in the proximal esophagus, and their presence correlates with a longer duration of disease (5). Squamous cell carcinoma of the esophagus has been rarely reported in patients with esophageal lichen planus; for this reason, early diagnosis is key.Figure 3. Esophageal lichen planus in a 73-year-old woman (same patient as in Fig 2). Barium esophograms show smooth long stricturing of the entire course of the esophagus with tapered margins (white arrow in A) and esophageal webs (black arrows in A). There are focal weblike strictures in an overall small-caliber lumen of the cervical esophagus (black arrow in B). Overall thin smooth luminal narrowing of the entire course of the esophagus is seen in C.Figure 3.Download as PowerPointOpen in Image Viewer Patients with esophageal lichen planus often present with dysphagia related to the strictures, with reflux-type symptoms, and weight loss. Strictures can be treated with balloon dilation, although this often requires regular repeat treatments (5). Endoscopic findings include superficial white papules, pseudomembranes, webs, and strictures.Disclosures of conflicts of interest.—All authors have disclosed no relevant relationships.AcknowledgmentWe thank Ciléin Kearns, MD, MBChB, for feedback and advice on the medical illustration in Figure 1.All authors have disclosed no relevant relationships.

Der Lichen planus des Ösophagus – Eine unterschätzte Erkrankung

An involvement of the esophagus in patients with lichen planus was described for the first time in 1982. Ever since, it has been seen as a rarity. However, studies over the last 10 years have shown a higher prevalence than expected. It may even be supposed that esophageal lichen planus (ELP) is more common than eosinophilic esophagitis. ELP mostly affects middleaged women. The principal symptom is dysphagia. Endoscopically, ELP is characterized by denudation and tearing of the mucosa, trachealization and hyperkeratosis and esophageal stenosis may occur in patients with long courses of the disease. Histologic findings including mucosal detachment, T-lymphocytic infiltrate, intraepithelial apoptosis (civatte bodies) and dyskeratosis are crucial. Direct immunofluorescence shows fibrinogen deposits along the basement membrane zone. So far, there is no well-established therapy but a treatment with topic steroids is effective in 2/3 of the patients. Common therapy of lichen planus of the skin seems to be ineffective for treatment of ELP. Symptomatic esophageal stenosis should be endoscopically dilated. ELP joins the group of "new" immunologic diseases of the esophagus.

Esophageal Lichen Planus Unusual Presentations: A Case Series.

Esophageal Lichen Planus (ELP)is a rare manifestation of Lichen Planus(LP). We present a case series of 2 patients with oral mucosal involvement who presented with dysphagia. On endoscopy, one patient revealed proximal esophageal stricture and the other patient had proximal esophageal ulcer. LP considered as a differential diagnosis in middle aged women with dysphagia.

Esophageal lichen planus: an unusual case of dysphagia.

An unusual case of chronic dypshagia associated with impaired quality of life in a 73-years old patient with past medical history of tongue squamous cell carcinoma. Prior esophagogastroduodenoscopy (EGD) with formalin-fixed biopsies has demonstrated inespecific findings. A few months later, new EGD was performed and esophageal stricture with sloughed mucosa was shown. With formaline and fresh biopsies was made the diagnosis of esophageal lichen planus. With medical treatment and dilations the patient had a good outcome. This is an underdiagnostic disease that has been associated with squamous cell carcinoma and impair quality of life due to the dysphagia. Immunohistochemistry can be useful for diagnosis and fresh biopsies should be considered to increase diagnostic sensitivity.

Esophageal Lichen Planus and Development of Dysplasia.

A 54-year-old woman with a 10-year history of esophageal lichen planus underwent an upper endoscopy because of a modest increase in dysphagia (Figure A). This revealed features of known lichen planus, including loss of normal vascular pattern and a whitish-lacy appearance without focal abnormalities, but random biopsies demonstrated high-grade dysplasia. For further evaluation, she underwent endoscopy with Lugol’s staining that revealed an area of focal nonstaining (Figure B), which was biopsied.

Esophageal lichen planus: Current knowledge, challenges and future perspectives.

Lichen planus (LP) is a frequent, chronic inflammatory disease involving the skin, mucous membranes and/or skin appendages. Esophageal involvement in lichen planus (ELP) is a clinically important albeit underdiagnosed inflammatory condition. This narrative review aims to give an overview of the current knowledge on ELP, its prevalence, pathogenesis, clinical manifestation, diagnostic criteria, and therapeutic options in order to provide support in clinical management. Studies on ELP were collected using PubMed/Medline. Relevant clinical and therapeutical characteristics from published patient cohorts including our own cohort were extracted and summarized. ELP mainly affects middle-aged women. The principal symptom is dysphagia. However, asymptomatic cases despite progressed macroscopic esophageal lesions may occur. The pathogenesis is unknown, however an immune-mediated mechanism is probable. Endoscopically, ELP is characterized by mucosal denudation and tearing, trachealization, and hyperkeratosis. Scarring esophageal stenosis may occur in chronic courses. Histologic findings include mucosal detachment, T-lymphocytic infiltrations, epithelial apoptosis (Civatte bodies), dyskeratosis, and hyperkeratosis. Direct immuno-fluorescence shows fibrinogen deposits along the basement membrane zone. To date, there is no established therapy. However, treatment with topical steroids induces symptomatic and histologic improvement in two thirds of ELP patients in general. More severe cases may require therapy with immunosuppressors. In symptomatic esophageal stenosis, endoscopic dilation may be necessary. ELP may be regarded as a precancerous condition as transition to squamous cell carcinoma has been documented in literature. ELP is an underdiagnosed yet clinically important differential diagnosis for patients with unclear dysphagia or esophagitis. Timely diagnosis and therapy might prevent potential sequelae such as esophageal stenosis or development of invasive squamous cell carcinoma. Further studies are needed to gain more knowledge about the pathogenesis and treatment options.

Esophageal Manifestations of Dermatological Diseases, Diagnosis and Management.

The purpose of this article is to discuss the diagnosis and treatment of diseases that affect both the skin and the esophagus. The diagnosis of dermatological conditions that affect the esophagus often requires endoscopy and biopsy with some conditions requiring further investigation with serology, immunofluorescence, manometry, or genetic testing. Many conditions that affect the skin and esophagus can be treated successfully with systemic steroids and immunosuppressants including pemphigus, pemphigoid, HIV, esophageal lichen planus, and Crohn's disease. Many conditions are associated with esophageal strictures which are treated with endoscopic dilation. Furthermore, many of the diseases are pre-malignant and require vigilance and surveillance endoscopy. Diseases that affect the skin and esophagus can be grouped by their underlying etiology: autoimmune (scleroderma, dermatomyositis, pemphigus, pemphigoid), infectious (herpes simplex virus, cytomegalovirus, human immunodeficiency virus), inflammatory (lichen planus and Crohn's disease), and genetic (epidermolysis bullosa, Cowden syndrome, focal dermal hypoplasia, and tylosis). It is important to consider primary skin conditions that affect the esophagus when patients present with dysphagia of unknown etiology and characteristic skin findings.

S2440 A Rare Cause of Dysphagia: Esophageal Stricture Due to Lichen Planus

Introduction: Esophageal lichen planus (ELP) is an unusual and under-recognized cause of dysphagia. Timely diagnosis is crucial for effective treatment as ELP has been associated with increased risk for development of squamous cell carcinoma. Case Description/Methods: A 72-year-old man presented with esophageal dysphagia to solids. Past medical history included oral lichen planus (LP) and osteoporosis with use of alendronate. He underwent endoscopy (EGD) which showed a proximal esophageal stricture for which balloon dilation ranging from 8 to 15 mm was done. Biopsy of the stricture showed esophageal mucosa with increased intraepithelial eosinophils (Figure). The working diagnosis was peptic stricture with possible eosinophilic esophagitis (EoE). He was started on pantoprazole 40 mg twice daily. He underwent 2 more EGDs with dilation for recurrent stricture and on the 2nd EGD, biopsy of the stricture showed numerous intraepithelial lymphocytes and focal apoptotic squamous cells (Civatte bodies) compatible with ELP. Budesonide slurry 1 mg twice daily was instituted and an EGD 6 months later showed near resolution of the stricture. The patient no longer requires dilations or antiacid therapy and is asymptomatic currently. He had Candida esophagitis 1 month after initiation of budesonide which was treated with fluconazole. Discussion: ELP is prevalent in patients with mucocutaneous forms of LP, most often oral LP. It is rarely seen in males with a case series by Franco et al describing the female to male ratio as 5:1. The endoscopic differential diagnosis for ELP should distinguish findings of esophagitis and stricture secondary to EoE, reflux esophagitis or esophageal Candidiasis. A low threshold should be kept for suspecting ELP in a patient with dysphagia and mucocutaneous LP. If histology is inconclusive but a high index of suspicion remains, particularly in patients with mucosal LP, repeating biopsies may be warranted for diagnosis as is highlighted in this case. A co-relation between longer duration of disease with severity of inflammation has been proposed with case series reporting strictures. Treatment includes serial dilations, topical and/or systemic steroids. Recurrence has been described despite topical steroid therapy with requirement of additional dilations. Successful use of immunomodulators such as cyclosporine, mycophenolate has been described. There is paucity of data regarding surveillance and optimal treatment for ELP, and thus further studies are needed for better understanding of this disease.Figure 1.: Esophageal biopsy showing esophageal squamous mucosa with basal cell hyperplasia, intraepithelial lymphocytes, and 2 apoptotic keratinocytes (Civatte or colloid bodies). Findings are compatible with esophageal lichen planus.

S2422 A Lichen for the Esophagus: A Rare Case of Esophageal Lichen Planus

Introduction: Lichen planus is an inflammatory condition of the skin and mucosal membranes. Sites of disease are variable and esophageal involvement is uncommon. We highlight a case of esophageal lichen planus masquerading as eosinophilic esophagitis. Case Description/Methods: A 59-year-old female with a past medical history of hypothyroidism status post thyroidectomy presents with progressive dysphagia and odynophagia to solids for 3 years. Symptoms initially began after thyroidectomy. Evaluation by ENT was notable for inflammatory changes of the oropharynx for which PPI trial was given for clinical features of silent reflux. Despite a 2-month course of therapy, symptoms persisted. Videofluoroscopic swallow study was unremarkable without evidence of aspiration or penetration. Subsequent EGD was notable for exudates, linear furrowing, and rings to suggest the diagnosis of eosinophilic esophagitis. Esophageal biopsy pathology features, however, showed band-like lymphocytic infiltration of the lamina propria and civatte bodies within the squamous epithelium consistent with esophageal lichen planus. Unfortunately, the patient was lost to follow up and subsequent treatment was unable to be initiated. Discussion: Esophageal lichen planus is an exceedingly rare entity with less than 100 documented case reports. It is likely underdiagnosed given that it can mimic other esophageal entities, such as eosinophilic esophagitis as seen in our patient. As such, histologic examination is necessary to identify key features of esophageal lichen planus which include lymphocytic infiltrates of the lamina propria as well as civatte bodies, which represent necrotic keratinocytes. Esophageal lichen planus has a tendency to be chronic and require topical or systemic therapy with steroids. Stricture development will typically require dilatation. Clinicians should consider esophageal lichen planus as part of their differential for dysphagia especially given the potential for malignant transformation to squamous cell carcinoma, which has been reported in 1-2% of cases.

S2254 Use of Upadacitinib in Refractory Esophageal Lichen Planus: Endoscopic Improvement in "Planus" Sight

Introduction: Lichen planus (LP) is an inflammatory skin condition that affects oropharyngeal and esophageal mucosa. Esophageal LP (ELP) has a prevalence of 0.19% but is thought to be underdiagnosed. It presents with ulceration, exudates, rings and/or strictures. Although pathogenesis of LP is incompletely understood, the JAK signaling pathway is thought to play a role. Upadacitinib is a selective JAK1 inhibitor approved for use in ulcerative colitis. We present a case of refractory ELP with endoscopic and histologic response to upadacitinib after failing standard treatment. Case Description/Methods: A 68-year-old female with history of Sjogren’s syndrome, LP, and prior peptic stricture at the gastroesophageal junction presented with dysphagia to both liquids and solids, intermittent reflux, regurgitation, and self-limited impactions. An EGD showed esophageal stenosis, severe esophagitis, and mucosal ulceration (Figure A). Passage of the scope resulted in dilation; however, formal dilation of stenosis was not performed due to severity of esophagitis. Esophageal biopsies revealed squamous mucosa with parakeratosis, dyskeratotic cells and scattered lymphocytes consistent with ELP. Subsequently, the patient recalled having a remote history of oral lichen planus. She was started on pantoprazole 40 mg twice daily and budesonide oral slurry with limited response. With co-management by gastroenterology and dermatology, she was initiated on mycophenolate 500 mg daily and increased to 2000 mg twice a day. She continued to lack both histologic and symptomatic improvement remaining limited to a soft and liquid diet resulting in a 20lb weight loss. She was started on monotherapy with upadacitinib 30 mg twice daily. This resulted in marked symptomatic recovery with repeat endoscopy 3 months later showing dramatic macroscopic and histologic improvement (Figure B), with only some residual fibrostenotic disease remaining (Figure C). Discussion: Multimodal treatment is typically employed in ELP with medical therapy and endoscopic dilation. Systemic or topical steroids are first line, with efficacy estimated at 60-70%. Other therapies include tacrolimus, cyclosporine, mycophenolate, rituximab, adalimumab, and tofacitinib, however data for these therapies are limited. To date, there are only 2 cases reported in the literature of successful treatment of oro-esophageal LP with upadacitinib. Given profound improvement seen in our patient, upadacitinib may offer another alternative for these difficult-to-treat patients.Figure 1.: 1a. ELP on initial diagnostic endoscopy before initiation of therapy. 1b. Follow up endoscopy performed after 12 weeks of upadacitinib treatment. 1c. Lichenoid esophagitis: lymphocytic infiltrates, focal histiocytic aggregate (blue arrow) and dyskeratosis (Civatte body, red arrow).

Correction to: Demystifying Esophageal Lichen Planus: A Comprehensive Review of a Rare Disease You Will See in Practice.

Correction to: Demystifying Esophageal Lichen Planus: A Comprehensive Review of a Rare Disease You Will See in Practice.

Acute Diseases of the Esophagus - Esophagitis

Acute Diseases of the Esopagus - Esophagitis Abstract. Inflammation of the esophagus can be caused by various conditions including gastroesophageal reflux (GERD), immunosuppression, infections, allergens, or distinct medications. GERD will be covered in a separate article. Clinical symptoms include heartburn, retrosternal pain, dysphagia, or fetor ex ore. Bleeding, strictures, or stenoses can occur as local complications. Besides a detailed medical history, diagnostic tools are usually an accurate physical examination and flexible endoscopy including histological and microbiological sampling. Immunosuppressive drugs, HIV, malignancies, and chronic alcohol abuse are often associated with candida esophagitis which is typically treated with fluconazole. History of allergies is especially relevant for eosinophilic esophagitis (EoE) which mostly affects young patients and can be treated with topical steroids. A rare but important differential diagnosis to EoE is esophageal lichen planus.

S357 Esophageal Lichen Planus: The Efficacy and Safety of Tacrolimus in Reducing Inflammation and Need for Dilation

Introduction: Esophageal Lichen Planus (ELP) is a rare inflammatory disease most commonly seen in middle-aged white women. It manifests with sloughing mucosa, thick white exudate, and proximal strictures. Most case reports and small series highlight the use of steroids, which are not preferred long-term. Other immunosuppressants have been reported with variable results. To our knowledge, oral tablet tacrolimus has not been studied. Our aim was to assess the change in ELP (inflammation, stricture, and disease extent) after treatment with oral tacrolimus. Methods: This was a retrospective cohort study. Consecutive adults with a confirmed diagnosis of ELP who underwent EGD by 2 esophagologists between 01/2011-07/2020 were eligible. Inflammation and fibrostenotic disease were graded using the ELP Severity Score, which we developed (Table). Difference in ELPSS across groups was assessed using Mann-Whitney U test and for categorical variables using the Fisher exact test. Time-to-recovery was assessed using the log-rank test. Statistical significance was 5% for all comparisons. Results: Twenty-2 patients underwent more than one EGD and were included in the study. Half (11) received tacrolimus (dose 1-2 mg BID) and half (11) received other therapy (i.e. cyclosporine, topical steroids, or none). There were no statistically significant differences in baseline characteristics between the groups (Tac and No-Tac). In the Tac group, mean age was 63, BMI 26, and 100% were female. The No-Tac group had mean age of 73, BMI 24, and 72% female. Extraesophageal manifestations in Tac and No-Tac were oral (100% vs 82%), anogenital (63% vs 27%), and skin (36% vs 9%). Most common symptom was dysphagia (100% both groups) followed by weight loss (27% both groups). Mean ELPSS on first EGD was similar between groups with 5.8 points (±1.8) for Tac and 5.9 points (±1.9) for No-Tac (P=0.9). Among patients on Tac vs No-Tac, there was a statistically significant improvement in ELPSS (mean difference 1.8 pts; 95% CI 0.25-3.38; P=0.02). Response rate was 89% with Tac vs 30% with No-Tac (P=0.025). See Figures 1A and 1B. All 22 patients underwent bougie dilation safely with a mean diameter of 16 mm achieved. Patients on Tac also required less frequent dilation compared to No-Tac. Conclusion: The use of oral tablet tacrolimus reduced the inflammatory and fibrostenotic components of ELP. Thus, utilizing low-dose oral tacrolimus (50-75% less than transplant dosages) is safe and should be considered in patients with severe disease.Figure 1.: Left image (A) shows the change in ELP Severity Score (ELPSS) between the 2 groups. Right image (B) represents the time-to-event function of the 2 groups.Table 1.: ELP Severity Score. Score range: 1-10. Interpretation: Mild (1-2), Moderate (3-4), Moderate-Severe (5-6), Severe (7-10). Superscripts: 1. Sloughing or peeling is spontaneous or with passage of scope only - not following dilatation. 2. Exudate classification: Mild describes scattered punctate exudates. Moderate disease shows short serpiginous plaques. Severe describes long, thick, serpiginous plaques. 3. ‘Multiple narrowing’ suggests strictures or general narrowing involving more than one location in esophagus.

S2108 Progression of Esophageal Lichen Planus to Squamous Papillomatosis and Squamous Cell Carcinoma

Introduction: Esophageal squamous papillomas (ESPs) are typically benign asymptomatic lesions. The pathogenesis is uncertain but has been associated with acid reflux and other mucosal irritants, as well as with HPV. This case presents a patient with a 25-year progression from symptomatic esophageal lichen planus (ELP), through ESPs to papillomatosis, and finally well differentiated papillary squamous cell carcinoma. Case Description/Methods: A 78-year old White female presented to the GI clinic in 2008 for dysphagia. She was 5’0” and 118 lbs with pertinent past medical history of ELP with associated stricture diagnosed in 1996. She was treated with multiple endoscopic dilations of the stricture due to recurrent dysphagia, many with triamcinolone injection. She was also treated with multiple courses of systemic glucocorticoids for months at a time. In 2009, a 10 mm squamous papilloma in the mid esophagus was found at EGD. The lesion was subsequently partially resected by snare polypectomy and completely ablated using argon plasma coagulation (APC). Over the next 6 years she underwent 20 EGDs with bougie dilation, roughly half of which included resection of ESPs and APC fulguration. On EGD in 2016 multiple polypoid ESPs were seen throughout the esophagus; some but not all lesions were resected. Microscopically, the lesions were inflamed squamous papillomas with variable atypia. The patient then moved out of town and was lost to follow-up. She was next seen in 9/2020 for dysphagia to solids with marked weight loss, now down to 76 lbs. EGD at that time revealed extensive squamous papillomatosis extending throughout the entire esophagus, with partial obstruction of the lumen. Dilation and partial resection of ESPs was performed. Subsequent EGD was performed with debulking of the esophageal lumen using hot and cold snares. Histologic examination demonstrated a spectrum of squamous papillomas with atypia to low grade papillary squamous cell carinoma. The patient had subsequent improvement in dysphagia and some weight gain. However she gradually developed recurrent dysphagia and declined further endoscopic intervention or feeding gastrostomy. She died at home in 5/2021. Discussion: ELP and ESPs have both been independently associated with rare malignant transformation. This is the second reported case, to our knowledge, of ELP progression through ESPs to SCC. This case supports a growing body of literature that either entity can harbor malignant potential, and surveillance endoscopy is reasonable.Figure 1.: Left: Origin of the aberrant right subclavian artery Right: Diagonal impression on esophagus from extrinsic compression.

Demystifying Esophageal Lichen Planus: A Comprehensive Review of a Rare Disease You Will See in Practice.

Lichen planus (LP) is a chronic inflammatory disorder that often affects the skin, hair, nails, and mucus membranes. Although esophageal involvement has traditionally been felt to be rare, recent reports suggest that it is often unrecognized or misdiagnosed. The diagnoses of esophageal lichen planus can be challenging and is suspected based on patients' endoscopic and histologic findings and in the context of their clinical history and physical examination. Physicians must have an index of suspicion, particularly in older white women and in those patients with an atypical esophagitis or stricturing disease, which do not respond to traditional treatment. Currently, there are limited data on esophageal lichen planus patients, and no formal management guidelines for this disease, which all gastroenterologists will see in practice. This article reviews the etiology and histopathology of LP and provides a comprehensive discussion of the clinical features, diagnosis, and management of esophageal disease from the gastroenterologist's perspective. Finally, we address the esophageal complications of LP.

Esophageal Lichen Planus with Dysplasia

Esophageal Lichen Planus with Dysplasia