Esophagus

• Lichenoid esophagitis is an umbrella term to cover a histologic pattern of injury; it is not a specific diagnosis
• Lichen planus can cause this pattern of injury
• In cases without evidence of skin disease or positive immunofluorescence (IF), the etiology can be quite variable, including:
  • Infections (especially HIV and viral hepatitis)
  • Crohn's disease
  • Medications (NSAIDs, antihypertensives, checkpoint inhibitors, antimalarial drugs)
  • Pill esophagitis
  • Rheumatologic disorders

Contributed by David Matthew Saulino, D.O. and David Hernandez Gonzalo, M.D.

• At endoscopy (Am J Surg Pathol 2013;37:1889)
  • White plaques or streaks are present, mimicking candidiasis or glycogenic acanthosis
  • In addition, it may cause ulceration in mid or proximal esophagus
  • Strictures can also be present

Contributed by David Matthew Saulino, D.O. and David Hernandez Gonzalo, M.D.

• Candida esophagitis:
  • Endoscopic findings (white plaques) can be similar to lichenoid esophagitis pattern
  • Microscopic similarities to lichenoid esophagitis pattern: numerous intraepithelial lymphocytes, superficial neutrophils, parakeratosis and Civatte bodies
  • Desquamated and hyperpink parakeratosis
  • Pseudohyphae and budding yeast: GMS positive (should always be performed when entertaining a diagnosis of lichenoid esophagitis pattern)
• Gastroesophageal reflux disease (GERD):
  • Predilection for distal esophagus
  • Basal cell hyperplasia, spongiosis and elongated papillae
  • Intraepithelial lymphocytes can be seen but are accompanied by eosinophils and rare neutrophils
  • Apoptotic keratinocytes not a diagnostic feature
• Lymphocytic esophagitis:
  • Lymphocytes tend to have a peripapillary distribution while in lichenoid esophagitis pattern prominent band-like lymphocytic infiltrate involves the interface of basal epithelium and lamina propria
  • In biopsies lacking lamina propria it is a challenge to assess the distribution of lymphocytes
• Eosinophilic esophagitis:
  • Endoscopically similar findings to lichenoid esophagitis pattern
  • Prominent eosinophils rather than lymphocytes
• Sloughing esophagitis:
  • Intraepithelial split while in lichenoid esophagitis pattern split is at the junction of the epithelium and lamina propria
  • Inflammation not prominent
• Isolated esophageal mucous membrane pemphigoid:
  • Positive immunofluorescence with linear deposits of IgG
  • Serum anti BP230 or BP180 antibodies
  • Treatment requires systemic immunosuppression and may be worsened by repeated dilations alone; should be considered in patients with unexplained dysphagia accompanied by mucosal sloughing, strictures and ulcerations (Am J Gastroenterol 2019;114:1695)
• Esophageal GVHD:
  • History of hematopoietic stem cell transplant
  • Intraepithelial lymphocytosis, basilar vacuolization, epithelial apoptosis and necrosis in severe disease
  • Esophageal webs or strictures in upper or mid third of the esophagus can be seen in chronic GVHD (Best Pract Res Clin Haematol 2008;21:251)

A 45 year old woman with dysphagia undergoes an upper endoscopy which demonstrates mucosal breaks involving at least 75% of esophageal circumference in mid esophagus. Tissue submitted for immunofluorescence study is negative and the patient has no skin, oral or genital lesions. An esophageal biopsy demonstrates the findings shown above. Which one of the following has been associated with this pattern of injury?


1. Cytomegalovirus
2. Herpes virus I/II
3. HIV and viral hepatitis
4. Sarcina ventriculi

C. HIV and viral hepatitis

HIV and viral hepatitis have been associated with lichenoid esophagitis pattern, shown here. Sarcina ventriculi is a Gram positive coccus, recognized in gastric biopsies, particularly of patients with delayed gastric emptying characterized by basophilic staining and tetrad arrangement. Cytomegalovirus causes viral cytopathic effect seen at the base of esophageal ulcers involving endothelial cells. Herpes virus I/II would show multinucleation, margination and molding (3 M’s) within superficial epithelial cells.

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Reference: Lichenoid esophagitis

Which of the followings is true regarding lichenoid esophagitis pattern of injury?


1. Dysphagia is not a common symptom in lichenoid esophagitis pattern patients
2. Stricture formation in mid esophagus can be seen in upper endoscopy
3. There are no reports of an association with squamous cell neoplasia
4. White plaques in distal esophagus of young men is the typical clinical scenario

B. Stricture formation in mid esophagus can be seen in upper endoscopy

Lichenoid esophagitis pattern has been rarely reported in association with dysplasia and carcinoma and periodic surveillance should be suggested. White plaques in proximal esophagus of middle aged women is a common endoscopic finding. Endoscopically it may mimic Candida esophagitis or eosinophilic esophagitis. Stricture formation can be seen but is not a common finding in lichenoid esophagitis pattern unlike lichen planus esophagitis. Mid esophagus is more frequently involved in lichenoid esophagitis pattern. Dysphagia is a common symptom at the time of endoscopy.

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Reference: Lichenoid esophagitis