Esophageal Hyperkeratosis and Multiple Esophageal Rings in a Patient With Recurrent Dysphagia: 806

Introduction: The purpose of this case presentation is to describe a patient with recurrent dysphagia who was found to have Esophageal Hyperkeratosis (EH), which remained stable over a period of 5 years. This is an 87-year-old female who presented in 2009 with worsening solid dysphagia without heartburn, with no history of smoking, ETOH use, asthma, skin lesions, or weight loss. An EGD revealed whitish plaques in the upper esophagus, multiple partial rings at the mid/lower third of the esophagus, a non-obstructive Shatzki’s ring, and a small hiatal hernia. Balloon dilation was performed and biopsy of the whitish plaques revealed keratinized esophageal mucosa with rare intraepithelial eosinophils. The patient was treated with 40 mg Omeprazole for 2 years. She returned in 2012 with similar complaints and had a repeat EGD revealing persistent white plaques of the upper esophagus. Balloon dilation was performed and biopsies demonstrated normal esophageal mucosa without eosinophils or hyperkeratosis. She remained asymptomatic off PPI therapy until she returned with recurrent dysphagia in 2014. A repeat EGD showed whitish plaques in the upper third of the esophagus, a Shatzki’s ring at the GE junction, and gastritis. Biopsies from the proximal third of the esophagus were taken and revealed squamous mucosa with hyperkeratosis and hypergranulosis. A review of all endoscopic pictures and histology slides revealed stability of these white plaques over a 5 year period. Esophageal Hyperkeratosis is a rare entity that reflects complete keratinization of the esophageal epithelium. Patients typically have heartburn and dysphagia, and a biopsy typically confirms the diagnosis. Multiple references describe esophageal hyperkeratosis as a complication of GERD. Our case highlights a patient with symptoms of EH, multiple esophageal rings requiring palliative therapies, and stable lesions over a 5 year period. It’s important for gastroenterologists to be able to differentiate various whitish lesions as they may represent a spectrum of conditions from benign mycotic exudates and Human papilloma viral infection, to dysplastic syndromes and squamous cell carcinoma. Association with cutaneous syndromes like Tylosis and Darier’s disease, Vitamin A and E deficiency, and alkali ingestion have also been reported. The relation of these lesions with esophageal rings is not clear, but may be attributed to GERD induced inflammation. Esophageal hyperkeratosis is a rarely described process that should be considered in patients with dysphagia or GERD. It is important to be knowledgeable of EH and able to differentiate it from other similar appearing lesions both on EGD and histologically.