S4285 The Diagnosis and Management of a Rare Case of Dysphagia: Esophageal Squamous Papillomatosis

Introduction: Esophageal papillomas (EP) are rare and benign solitary lesions of squamous tissue incidentally found in the esophagus. EP is not fully understood, but postulated risk factors include chronic mucosal disruption, human papilloma virus, and mechanical injury. Diffuse or extensive EP, called esophageal squamous papillomatosis (ESP), is considered exceedingly rare and to our knowledge only 53 cases have been reported. Presented here is a severe case of ESP managed with endoscopic liquid nitrogen spray cryotherapy and serial dilation. Case Description/Methods: A 70-year-old man with longstanding dysphagia presented to the Veterans Affairs Medical Center for worsening dysphagia. Initial esophagogastroduodenoscopy (EGD) revealed a 6 mm distal esophageal stricture with friable mucosa. Despite proton pump inhibitor compliance, follow-up EGDs continued to demonstrate an intrinsic stricture. Two months later, an esophageal mass-like area within the proximal esophagus was noted. Pathology results confirmed ESP without dysplasia or malignancy. Intermittent endoscopic liquid nitrogen spray cryotherapy with dilation was performed. However, later that year the patient presented to the hospital with severe malnutrition and failure to thrive. EGD revealed ESP proliferation with a near total occlusion of the esophagus including a “ball valving” component of pedunculated tissue. Enteral feeding was initiated but persistent malnutrition and comorbidities precluded esophagectomy. It was then decided to perform spray cryotherapy with dilation every 7-10 days over the course of 6 weeks. This treatment resulted in a near absence of ESP and improvement in inner diameter to 15 mm. The patient was able to tolerate a soft diet for the first time in 3 years. Discussion: This case underscores the therapeutic potential of cryotherapy in ESP, an entity with an unclear natural history and no formalized treatment guidelines. While esophagectomy is curative, comorbidities precluded surgery for this patient. Cryotherapy in this case achieved increased luminal diameter allowing for oral intake, whereas dilation or proton pump inhibitor therapy alone had not. It is yet to be determined how effective cryotherapy is in the treatment of ESP over time but this case adds to the limited literature supporting cryotherapy as a viable intervention in severe ESP.