Lichenoid esophagitis

Topic Completed: 2 January 2020

Minor changes: 29 June 2020

Copyright: 2003-2019,, Inc.

PubMed Search: (Lichenoid OR lichen planus) esophagitis

David Matthew Saulino, D.O.
David Hernandez Gonzalo, M.D.
Page views in 2019: 2,080
Page views in 2020 to date: 1,187
Cite this page: Saulino D, Hernandez Gonzalo D. Lichenoid esophagitis. website. Accessed August 11th, 2020.
Definition / general
  • Lichenoid esophagitis is an umbrella term to cover a 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
    • Medication induced (NSAIDs, antihypertensives, checkpoint inhibitors, antimalarial drugs)
    • Pill esophagitis
    • Rheumatologic disorders
Essential features
  • Pattern of injury ("lichenoid esophagitis pattern or LEP")
  • Proximal and mid esophagus of middle aged or elderly women
  • Endoscopy often shows white plaque or streaks
  • Civatte bodies and characteristic distribution of lymphocytes
  • Umbrella term with many different etiologies
ICD coding
  • ICD-10: K20.9 - esophagitis, unspecified
  • Mid esophagus more frequently involved in lichenoid esophagitis pattern; upper and lower esophagus more frequently involved in lichen planus esophagitis
  • Lichen planus appears to be mediated by cytotoxic CD8 T cells that attack an antigen in the basal epithelium in a manner resembling graft versus host disease (Dis Esophagus 2003;16:47)
  • Predisposing factors for oral lichen planus include medications such as antimalarial drugs, NSAIDs, antihypertensive agents and dental materials such as amalgam
  • Lichen planus
  • Infections (especially HIV and viral hepatitis)
  • Upper tract Crohn's disease
  • Medications: nivolumab and other checkpoint inhibitors, antimalarial drugs, gold, NSAIDs and thiazides (ACG Case Rep J 2017;4:e57)
  • Mucosa physically damaged by nearby pill esophagitis
  • Rheumatologic disorders
Clinical features
  • Rheumatologic diseases more common in patients with lichen planus esophagitis (24%) versus lichenoid esophagitis pattern (11%) (Am J Surg Pathol 2013;37:1889)
  • Viral hepatitides and human immunodeficiency virus (HIV) infections are associated with lichenoid esophagitis pattern (Am J Surg Pathol 2013;37:1889)
  • There is overlap with gross appearance, diagnosis is made upon histologic assessment of biopsy
Prognostic factors
Case reports
  • Corticosteroids for esophageal lichen planus
  • Esophageal dilation for patients with stricture
Clinical images

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

Grade D esophagitis: mucosal
breaks which involve at least 75%
of the esophageal circumference

Microscopic (histologic) description
  • Prominent band-like lymphocytic infiltrate involving the interface of basal epithelium and lamina propria (this feature cannot be evaluated in biopsies lacking lamina propria) (Am J Surg Pathol 2013;37:1889)
  • Intraepithelial lymphocytosis
  • Dyskeratotic keratinocytes (Civatte bodies)
  • Acanthosis
  • Junctional split seen at the junction of the epithelium and lamina propria (unlike sloughing esophagitis)
Microscopic (histologic) images

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

Lymphocytes and dyskeratosis

Civatte bodies

Immunofluorescence description
  • Negative in lichenoid esophagitis pattern
  • In lichen planus esophagitis, globular IgM deposits at the junction of the squamous epithelium and lamina propria as well as complement staining in apoptotic keratinocytes
Positive stains
  • Predominance of T lymphocytes (CD3) in the epithelium and lamina propria with scattered CD20 positive B lymphocytes
Negative stains
Sample pathology report
  • Proximal esophagus, biopsy:
    • Esophageal squamous mucosa with lichenoid esophagitis pattern of injury (see comment)
    • Comment: The biopsy demonstrates a prominent band-like lymphocytic infiltrate involving the interface of lamina propria and epithelium, intraepithelial lymphocytes and dyskeratotic keratinocytes. Unfortunately, this pattern of injury is not entirely specific and can be seen as an esophageal manifestation of lichen planus, viral infections (particularly HIV and viral hepatitis), Crohn's disease, medications (NSAIDs, antihypertensive agents, antimalarial drugs) or pill esophagitis. Correlation with the clinical findings (in particular with cutaneous, oral or genital lesions) is suggested. If lichen planus is a consideration, additional biopsies with fresh tissue for immunofluorescence studies are worth performing. No fungal organisms were identified on the GMS stain. There is no dysplasia.
Differential diagnosis
  • 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
  • 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 maybe 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 acute GVHD:
    • History of hematopoietic stem cell transplant
    • Intraepithelial lymphocytosis, basilar vacuolization, epithelial apoptotic 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)
Board review style question #1

    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 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. Sarcina ventriculi
  2. HIV and viral hepatitis
  3. Cytomegalovirus
  4. Herpes virus I/II
Board review answer #1
B. HIV and viral hepatitis

Explanation: 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. HIV and viral hepatitis have been associated with lichenoid esophagitis pattern, shown here. Cytomegalovirus is seen at the base of esophageal ulcers involving endothelial cells. Herpes virus I/II would show multinucleation, margination and molding (3 Ms) within superficial epithelial cells.

Reference: Lichenoid esophagitis

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Board review style question #2
    Which of the followings is true regarding lichenoid esophagitis pattern of injury?

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

Explanation: 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.

Reference: Lichenoid esophagitis

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