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Lichenoid esophagitis presenting as fatal upper gastrointestinal bleeding in a 52 year-old woman: a case diagnosed by autopsy.

ABSTRACT: "Lichenoid esophagitis" is a descriptive term for a lichenoid pattern of inflammation in the esophagus for which a precise histologic diagnosis cannot be established. The differential diagnosis includes lichen planus, a drug-related reaction, and viral infection. Lichenoid esophagitis causing death has not been reported previously. We describe a case, diagnosed by autopsy, of lichenoid esophagitis in which massive bleeding from generalized epithelial sloughing and a large longitudinal ulcer proved fatal.A 52 year-old diabetic woman collapsed at her home in front of an acquaintance. "Bloody vomit" was noted. Despite resuscitation efforts, the patient died. A complete autopsy was performed. The middle portion of the esophagus showed a 9 cm longitudinal ulcer situated 12 cm from the esophago-gastric junction. Microscopic examination showed complete sloughing of the esophageal epithelium with a striking subepithelial lichenoid lymphocytic infiltrate extending into the muscularis mucosae. The findings were considered compatible with lichenoid esophagitis. Laboratory studies also showed the presence of diabetic ketoacidosis.Lichenoid esophagitis is an appropriate diagnostic term when clinical, histologic and laboratory findings do not allow for specific categorization of lichenoid inflammation in the esophagus. As illustrated here for the first time, lichenoid esophagitis may cause ulceration and mucosal sloughing severe enough to result in massive upper gastrointestinal bleeding and death. Translating these autopsy findings to the clinical setting, it is possible that the endoscopic finding of a longitudinal mid-esophageal ulcer in the presence of proximal stricture may be indicative of underlying lichenoid esophagitis.

SUBMITTER: Mitchell A

PROVIDER: S-EPMC5549324 | biostudies-other | 2017 Aug

REPOSITORIES: biostudies-other

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Project description:BackgroundUpper gastrointestinal (GI) bleeding is one of the most common, high risk emergency disorders in the western world. Almost nothing has been reported on longer term prognosis following upper GI bleeding. The aim of this study was to establish mortality up to three years following hospital admission with upper GI bleeding and its relationship with aetiology, co-morbidities and socio-demographic factors.MethodsSystematic record linkage of hospital inpatient and mortality data for 14 212 people in Wales, UK, hospitalised with upper GI bleeding between 1999 and 2004 with three year follow-up to 2007. The main outcome measures were mortality rates, standardised mortality ratios (SMRs) and relative survival.ResultsMortality at three years was 36.7% overall, based on 5215 fatalities. It was highest for upper GI malignancy (95% died within three years) and varices (52%). Compared with the general population, mortality was increased 27-fold during the first month after admission. It fell to 4.3 by month four, but remained significantly elevated during every month throughout the three years following admission. The most important independent prognostic predictors of mortality at three years were older age (mortality increased 53 fold for people aged 85 years and over compared with those under 40 years); oesophageal and gastric/duodenal malignancy (48 and 32 respectively) and gastric varices aetiologies (2.8) when compared with other bleeds; non-upper GI malignancy, liver disease and renal failure co-morbidities (15, 7.9 and 3.9); social deprivation (29% increase for quintile V vs I); incident bleeds as an inpatient (31% vs admitted with bleeding) and male patients (25% vs female).ConclusionOur study shows a high late as well as early mortality for upper GI bleeding, with very poor longer term prognosis following bleeding due to malignancies and varices. Aetiologies with the worst prognosis were often associated with high levels of social deprivation.

Project description:Objective To compare the predictive accuracy and clinical utility of five risk scoring systems in the assessment of patients with upper gastrointestinal bleeding.Design International multicentre prospective study.Setting Six large hospitals in Europe, North America, Asia, and Oceania.Participants 3012 consecutive patients presenting over 12 months with upper gastrointestinal bleeding.Main outcome measures Comparison of pre-endoscopy scores (admission Rockall, AIMS65, and Glasgow Blatchford) and post-endoscopy scores (full Rockall and PNED) for their ability to predict predefined clinical endpoints: a composite endpoint (transfusion, endoscopic treatment, interventional radiology, surgery, or 30 day mortality), endoscopic treatment, 30 day mortality, rebleeding, and length of hospital stay. Optimum score thresholds to identify low risk and high risk patients were determined.Results The Glasgow Blatchford score was best (area under the receiver operating characteristic curve (AUROC) 0.86) at predicting intervention or death compared with the full Rockall score (0.70), PNED score (0.69), admission Rockall score (0.66, and AIMS65 score (0.68) (all P<0.001). A Glasgow Blatchford score of ≤1 was the optimum threshold to predict survival without intervention (sensitivity 98.6%, specificity 34.6%). The Glasgow Blatchford score was better at predicting endoscopic treatment (AUROC 0.75) than the AIMS65 (0.62) and admission Rockall scores (0.61) (both P<0.001). A Glasgow Blatchford score of ≥7 was the optimum threshold to predict endoscopic treatment (sensitivity 80%, specificity 57%). The PNED (AUROC 0.77) and AIMS65 scores (0.77) were best at predicting mortality, with both superior to admission Rockall score (0.72) and Glasgow Blatchford score (0.64; P<0.001). Score thresholds of ≥4 for PNED, ≥2 for AIMS65, ≥4 for admission Rockall, and ≥5 for full Rockall were optimal at predicting death, with sensitivities of 65.8-78.6% and specificities of 65.0-65.3%. No score was helpful at predicting rebleeding or length of stay.Conclusions The Glasgow Blatchford score has high accuracy at predicting need for hospital based intervention or death. Scores of ≤1 appear the optimum threshold for directing patients to outpatient management. AUROCs of scores for the other endpoints are less than 0.80, therefore their clinical utility for these outcomes seems to be limited.Trial registration Current Controlled Trials ISRCTN16235737.

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Lichenoid esophagitis presenting as fatal upper gastrointestinal bleeding in a 52 year-old woman: a case diagnosed by autopsy.

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