Gastrointestinal · Year 2 · from Gastrointestinal
Case 2: Eosinophilic Esophagitis
Patient Presentation
Demographics: 28-year-old male
Chief Complaint: Recurrent food impaction
History of Present Illness: The patient presents to the emergency department with food stuck in his chest for 6 hours after eating steak. This is his third food impaction in 2 years. Between episodes, he reports chronic dysphagia to solid foods and has learned to "eat slowly and drink lots of water with meals." He avoids bread and meat when dining out. He has a history of seasonal allergies and childhood asthma.
Past Medical History: Allergic rhinitis, childhood asthma (resolved), eczema
Family History: Mother has asthma and food allergies
Physical Examination
- Vital Signs: Normal
- General: Anxious male, spitting saliva, unable to swallow
- Neck: No masses or lymphadenopathy
- Chest: Clear bilaterally
Workup and Results
- Upper Endoscopy (emergent for disimpaction): Meat bolus in mid-esophagus, successfully removed; esophageal findings include concentric rings ("trachealization"), linear furrows, and white exudates
- Esophageal Biopsies: >40 eosinophils per high-power field throughout esophagus; no eosinophilia in gastric or duodenal biopsies
Endoscopic appearance of eosinophilic esophagitis showing characteristic findings: concentric rings (trachealization/feline esophagus), linear furrows, and white mucosal plaques representing eosinophilic microabscesses.
Image Source: Wikimedia Commons, CC BY-SA 3.0
Diagnosis
Eosinophilic Esophagitis (EoE)
Clinical Correlation
Eosinophilic esophagitis is a chronic immune-mediated disease characterized by esophageal dysfunction and eosinophil-predominant inflammation. The diagnostic criterion is >/=15 eosinophils per high-power field on biopsy after excluding other causes. The condition typically affects young males with atopic history (allergies, asthma, eczema). Chronic inflammation leads to fibrotic remodeling with stricture formation, explaining food impaction as a classic presentation. The rings give a "corrugated" or "trachealized" appearance.
Treatment
- Initial trial of PPI (some EoE responds to acid suppression)
- If PPI-refractory: swallowed topical corticosteroids (fluticasone MDI swallowed or budesonide slurry) for 8 weeks
- Consider elimination diet (six-food elimination: dairy, wheat, eggs, soy, nuts, seafood)
- Esophageal dilation for symptomatic stricture (with caution - friable mucosa)
- Dupilumab (anti-IL-4/IL-13 biologic) for refractory cases