Esophageal manifestations of dermatologic disease

Esophageal Manifestations of Dermatological Diseases, Diagnosis and Management

Purpose of Review

The purpose of this article is to discuss the diagnosis and treatment of diseases that affect both the skin and the esophagus.

Recent Findings

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.

Summary

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.

Esophageal Nikolsky's Sign: A Rare Finding in a Patient with Bullous Pemphigoid

Bullous pemphigoid (BP) is a chronic relapsing autoimmune blistering disease that typically affects middle-age and elderly patients. It can manifest with varying degrees of mucosal involvement in addition to characteristic skin findings. However, esophageal involvement is very rare. We report a case of a 57-year-old female with BP who presented with epigastric pain and melena. She underwent an esophagogastroduodenoscopy which induced bullae seen only upon withdrawal of the endoscope. This finding is analogous to the dermatological finding of Nikolsky's sign. Gentle insertion and withdrawal of the endoscope is recommended to reduce the risk of bullae formation and mucosal injury.

Esophageal contractions in patients with chronic progressive external ophthalmoplegia

BACKGROUND

Chronic progressive external ophthalmoplegia is a mitochondrial myopathy that causes muscular or multisystem symptoms and has dysphagia as one manifestation.

AIM

To evaluate esophageal contractions in patients with chronic progressive external ophthalmoplegia.

METHODS

We studied 14 patients with chronic progressive external ophthalmoplegia and 16 asymptomatic volunteers. The diagnosis of the disease was established by the clinical picture and by mitochondrial DNA analysis in skeletal muscle. We used the manometric method with a perfusion catheter that recorded the esophageal contractions at 2, 7, 12, 17, and 22 cm from the lower esophageal sphincter (LES). All subjects performed in the supine position 20 swallows of a 5-ml bolus of water at room temperature, ten every 30 s and ten every 10 s.

RESULTS

The amplitude, duration, and area under the curve of contractions at 17 and 22 cm from the LES were lower in patients than in volunteers for swallows performed at 10-s and 30-s intervals (P<0.01). There was no difference in contractions at 7 and 2 cm, except for the contractions at 2 cm after swallows performed at 30-s intervals. The interval between the onset of contractions between 7 and 2 cm and between 22 and 2 cm was lower in patients than in volunteers, with swallows performed every 10 s and every 30 s.

CONCLUSION

There is impairment of esophageal contractions in patients with chronic progressive external ophthalmoplegia, mainly in the proximal esophageal body.

Lichen planus of the esophagus: what dermatologists need to know

BACKGROUND

Esophageal lichen planus (ELP) is a rare manifestation of mucocutaneous lichen planus (LP).

OBJECTIVES

We aimed to report our experience and review all cases of ELP reported in the English-language literature.

METHODS

We report our experience with 4 cases and reviewed PubMed for reports of ELP. Cases were evaluated for age of onset, sex, location of LP, relationship of the onset of ELP to extra-ELP, endoscopic findings, whether biopsy was performed, histopathology of esophageal biopsy specimens, medical history (including gastrointestinal history), development of esophageal squamous cell carcinoma, therapies tried, and response to treatment.

RESULTS

A total of 72 cases of ELP were studied. In all, 87% of patients were female, with a median age of 61.9 years at time of diagnosis. Dysphagia was present in 81% and odynophagia was present in 24%. Oral LP was present in 89%, anogenital/vulvar LP in 42%, and cutaneous LP in 38%. Fourteen patients developed ELP as the sole or first manifestation of LP. Proximal esophageal lesions were present in 64%, distal in 11%, and both proximal and distal in 26%. Histology was "consistent with" LP in 71%. Four patients developed squamous cell carcinoma in association with ELP.

LIMITATIONS

This is a review of our cases and others reported in the literature.

CONCLUSIONS

ELP is underrecognized and underreported. There is often a significant delay between the onset of symptoms and the diagnosis. Malignant transformation of ELP to squamous cell carcinoma has been reported.

How to manage refractory GERD

Patients who are unresponsive to 4-8 weeks' treatment with PPIs twice daily might have so-called refractory GERD. The first investigation these patients should undergo is upper endoscopy to exclude a diagnosis of peptic ulcer disease or cancer and identify the presence of esophagitis. The presence of esophagitis in these patients is suggestive of a pill-induced injury, an autoimmune skin disease involving the esophagus, eosinophilic esophagitis or, less likely, a hypersecretory syndrome or a genotype that confers altered metabolism of PPIs. Refractory reflux syndromes associated with normal endoscopy findings are more problematic to diagnose and further testing may be required, including prolonged 48 h pH testing, impedance measurements (for nonacid reflux), esophageal manometry and gastric function tests. For patients with refractory GERD who do not have esophagitis, possible etiologies include nocturnal gastric acid breakthrough, nonacid GER, missed GER or other diseases such as achalasia, gastroparesis or functional heartburn.