S4274 Refractory Esophagitis and Stricture Mistreated With Fundoplication: Think About Lichen Planus

Introduction: Esophageal lichen planus (ELP) is a chronic immune-mediated inflammatory condition which primarily affects middle-aged to older women and often coexists with oral or genital lichen planus. Due to its nonspecific symptoms and overlap with other esophageal disorders, ELP is often under recognized and misdiagnosed. We present 2 cases initially misdiagnosed and treated with fundoplication. Case Description/Methods: Case 1: A 67-year-old woman presented with a 2-year history of progressive dysphagia to solids and liquids without heartburn or regurgitation. Prior endoscopy showed diffuse esophageal inflammation and ulcers. She failed high-dose proton pump inhibitors therapy and underwent robotic hiatal hernia with Nissen fundoplication. Postoperative symptoms persisted. Barium esophagram revealed a diffusely narrowed esophagus with a 4 cm stricture in the upper thoracic esophagus and a lodged barium tablet. Repeated endoscopy showed severe mucosal friability, sloughing, and ulceration. ELP was diagnosed. She started on low dose oral tacrolimus and endoscopic steroid injection. Case 2: A 66-year-old woman was referred for refractory esophageal stricture and dysphagia without reflux symptoms. She had previously undergone Nissen fundoplication for presumed reflux-related stricture. Despite one month budesonide and daily dexlansoprazole, symptoms and inflammation persisted, requiring monthly dilations. Esophagram showed a narrow thoracic esophagus with a barium table lodged above the aortic arch. Repeated endoscopy identified a proximal stenosis impassable by the scope, dilated to 12 mm using a Savary dilator, diffuse mucosal sloughing, altered texture, decreased vascularity, and narrow caliber. Biopsy showed superficial squamous mucosa with lymphocytic inflammation and minimal submucosal tissue. Immunofluorescence was negative for immunoglobulins but positive for strong shaggy fibrinogen deposition along the basement membrane, consistent with a lichenoid tissue reaction. She was diagnosed with esophageal lichen planus. She started treatment with topical steroids. Discussion: Diagnosing ELP requires clinical, endoscopic, and histologic correlation with high index of suspicion. It is essential to biopsy both affected and adjacent mucosa. ELP should be considered in atypical or refractory esophagitis or stricturing diseases, particularly in middle-aged or older white women. Management involves topical or systemic immunosuppression and serial esophageal dilation.