Diffuse esophageal parakeratosis

A 31-year-old woman, who suffered from chronic alcohol abuse, presented with hematemesis and loss of consciousness 2 hours after ingesting toilet bowl cleaner and sedative pills. Over the previous 6 months she had suffered worsening depressive symptoms, with increased alcohol intake, inadequate diet, and a rapid weight loss of 20 kg. An urgent endoscopy revealed extensive gastric and duodenal hemorrhage as a result of caustic injury. The esophagus was not a source of bleeding; however, it showed an unusual appearance of thick mucosa with orderly displayed rings and furrows (Figure [1] a). The furrows were particularly prominent when the lumen constricted upon irrigation (Figure [1] b). The lesion started with discrete patches at the upper esophagus (Figure [1] c), extended diffusely through the entire esophagus, and ended up at the esophagogastric junction. A section of square-shaped mucosa at the upper esophagus was peeled off by random grasping using biopsy forceps (Figure [1] d). Epithelial parakeratosis was demonstrated by microscopic examination (Figure [2]). The patient was treated with alcohol abstinence, proton-pump inhibitor, standard tube-feeding diet, and supplements of thiamine, pyridoxine, and cyanocobalamine. A follow-up endoscopy 40 days later revealed normal esophageal mucosa except for scattered candidal infections.

Figure 1 Endoscopic finding of diffuse esophageal mucosal thickening. a Thick mucosa with orderly displayed rings and furrows. b Prominent furrows during lumen constriction. c The upper esophagus showing discrete lesion patches. d Random grasping with biopsy forceps removed a square-shaped section of mucosa at the upper esophagus.

Figure 2 Biopsy of upper esophagus reveals a dense layer of parakeratosis covering the normal-appearing squamous epithelium (hematoxylin and eosin, original magnification × 100).

Diffuse esophageal hyper-/parakeratosis is an uncommon endoscopic finding. It is associated with conditions like tylosis, mucosal hyperkeratosis syndrome, and pachyonychia congenita [1]. In addition to genetic diseases, it may be linked to ethanol exposure, duodenal reflux, riboflavin deficiency, and zinc deficiency [2] [3] [4] [5]. Rapid and complete recovery after nutritional supplement in this patient suggests a causal-result relationship between them.

Endoscopy_UCTN_Code_CCL_1AB_2AC_3AH

References

• 1 Ashworth M T, Nash J R, Ellis A. et al . Abnormalities of differentiation and maturation in the oesophageal squamous epithelium of patients with tylosis: morphological features.  Histopathology. 1991;  19 303-310
• 2 Korsten M A, Worner T M, Feinman L. et al . Balloon cytology in screening of asymptomatic alcoholics for esophageal cancer, Part I.  Dig Dis Sci. 1985;  30 845-851
• 3 Clark G W, Smyrk T C, Mirvish S S. et al . Effect of gastroduodenal juice and dietary fat on the development of Barrett’s esophagus and esophageal neoplasia: an experimental rat model.  Ann Surg Oncol. 1994;  1 252-261
• 4 Foy H, Kondi A. The vulnerable esophagus: riboflavin deficiency and squamous cell dysplasia of the skin and the esophagus.  J Natl Cancer Inst. 1984;  72 941-948
• 5 Barney G H, Orgebin-Crist M C, Macapinalac M P. Genesis of esophageal parakeratosis and histologic changes in the testes of the zinc-deficient rat and their reversal by zinc repletion.  J Nutr. 1968;  95 526-534