Dysphagia and Odynophagia in a Woman With Hypothyroidism

Xiang Liu, MD; John W. Birk, MD


May 03, 2023

Advanced esophageal cancer presents with weight loss and 3-6 months of progressive dysphagia to solids then liquids as the mass enlarges circumferentially to cause greater obstruction. In the United States, esophageal adenocarcinoma is the predominant esophageal cancer. Although Barrett esophagus due to gastroesophageal reflux disease (GERD) is a premalignant condition for the development of esophageal adenocarcinoma, 40% of patients who receive a diagnosis of adenocarcinoma do not have GERD.[1]

Eosinophilic esophagitis is more common in younger men and is often diagnosed when the patient presents with food impaction.[2] The diagnosis is made by pathohistologic examination of an esophageal biopsy specimen, which reveals at least 15 eosinophils per high-power field.[2]

Esophageal lichen planus (ELP) is not very well studied, and the true prevalence of this underdiagnosed disorder remains to be determined. It is considered rare; however, it may be more common than previously thought. Most literature is from case reports and small case series.

ELP is predominantly found in women (80%), and the median age of presentation is 60 years.[3] Mucocutaneous lichen planus affects about 0.5%-2% of the population.[4] Some studies show that as many as 50% of patients with oral lichen planus have esophageal involvement.[5] However, ELP can occur as an isolated manifestation, as in this patient. Mucocutaneous lichen planus is commonly associated with autoimmune disease, such as autoimmune thyroiditis. Mucous membrane lesions without skin manifestations occur in 30%-70% of patients with lichen planus.[6]

Dysphagia is the predominant symptom in 80% of patients with ELP; however, about 20% of patients are completely asymptomatic.[5] Other common symptoms include odynophagia, weight loss, heartburn, regurgitation, hoarseness, and cough. The severity of ELP correlates with the severity of dysphagia.[5]

Diagnosis of ELP can be challenging because its endoscopic appearance may mimic many other diseases, such as eosinophilic esophagitis and other types of ulcerative esophagitis. Without careful and intentional investigation by a pathologist, typical features of ELP can often be missed. Esophagrams should not solely be used to diagnose ELP because a patient with ELP can have a normal esophagram; however, suggestive features include a small-caliber esophagus and segmental strictures.[7] Endoscopy is crucial in making the diagnosis of ELP. Common endoscopic features include ulceration, peeling of friable mucosa, proximal to mid esophageal stricture, and reticulated white streaks and/or mucosa.

Pathohistologic findings in patients with ELP include lymphocytic infiltrates, parakeratosis, hyperkeratosis, and dyskeratosis. Direct immunofluorescence shows fibrinogen deposits along the basement membrane.[5]

Chronic ELP leads to the development of strictures, which result in dysphagia. It is also associated with an increased risk for squamous cell carcinoma.[8] The prevalence of hepatitis C and primary biliary cirrhosis is high among patients with lichen planus; thus, screening for these disorders may be considered.[9,10]


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