Multiple esophageal webs (feline esophagus): Case reports of the endoscopic and pathological characteristics of 10 patients

Background: Multiple esophageal webs (also called "feline esophagus" or "funnel shaped esophagus") are an extremely rare cause of dysphagia and have a poorly understood etiology. Desquamation of the esophageal mucosa due to bullous disease or graft versus host disease (GVHD) have been implicated as etiologic factors. Caustic injury or reflux disease is less implicated as this is mainly a disease of the mid esophagus. Here we report our experience with 10 patients. During a 4 year period we identified 10 patients with feline esophagus based on their characteristic endoscopic features. There were 8 men and 2 women. The mean age was 35.8 yr. All the patients complained of chronic intermittent dysphagia for solids (duration 6 months-17 yrs). There was no h/o caustic injury, dermatologic disorders, chronic reflux or GVHD. Endoscopic Findings: All 10 patients had numerous circumfrential web-like constrictions in the esophagus that did not flatten out with insufflation. These webs were located in mid esophagus (6 pts.), upper and mid esophagus (2 pts.) and throughout the esophagus (2 pts.). The overlying mucosa appeared normal. One patient, on 2 separate procedures, was noted to have mucosal peeling throughout the esophagus with minimal contact (Nikolsky's sign). Pathology: Forceps biopsies of the mucosa on microscopy showed marked acute and chronic inflammation, basilar cell hyperplasia and extensive eosinophilic infiltration. No dysplasia was noted. Special stains for immunofloresence and complement (C3), consistent with bullous disease, were positive in 3 patients. Conclusion: The association between epidermolysis bullosa, mucus membrane pemphigoid and esopageal webs is well established. However, none of our patients had skin manifestations so the clinical significance of biopsies consistent with bullous disease is unclear. The possibility of a localized immunologic reaction in the esophagus needs to be further explored.