# Clinical Cases: Esophageal Disorders

## Case 1: Gastroesophageal Reflux Disease with Barrett's Esophagus

### Patient Presentation
**Demographics:** 62-year-old male

**Chief Complaint:** Chronic heartburn for 20 years with recent worsening dysphagia

**History of Present Illness:** The patient has experienced heartburn and regurgitation for over two decades, managed with intermittent over-the-counter antacids and PPIs. Over the past 6 months, he has noticed solid foods "sticking" in his lower chest, requiring multiple sips of water to pass. He has lost 8 pounds unintentionally. He denies odynophagia or hematemesis.

**Past Medical History:** Obesity (BMI 32), hypertension, hyperlipidemia

**Social History:** 25 pack-year smoking history (quit 10 years ago), occasional alcohol use

### Physical Examination
- **Vital Signs:** BP 142/88 mmHg, HR 76 bpm
- **General:** Obese male in no acute distress
- **Abdomen:** Soft, obese, non-tender
- **Cardiac/Pulmonary:** Unremarkable

### Workup and Results
- **Upper Endoscopy:** Long-segment Barrett's esophagus (8 cm) with a nodular area; distal esophageal stricture at 36 cm
- **Histopathology:** Intestinal metaplasia with goblet cells; nodular area shows high-grade dysplasia
- **CT Chest/Abdomen:** No lymphadenopathy or metastatic disease

![Barrett's Esophagus with Dysplasia](case_01_image.jpg)
*Endoscopic image showing Barrett's esophagus with salmon-colored columnar mucosa extending above the gastroesophageal junction. The irregular nodular area (arrow) was found to harbor high-grade dysplasia on biopsy.*

**Image Source:** Wikimedia Commons, CC BY-SA 4.0

### Diagnosis
**Barrett's Esophagus with High-Grade Dysplasia and Peptic Stricture**

### Clinical Correlation
Barrett's esophagus represents intestinal metaplasia in response to chronic acid exposure. The progression from non-dysplastic Barrett's to low-grade dysplasia, high-grade dysplasia, and invasive adenocarcinoma follows a predictable sequence. High-grade dysplasia carries 5-10% annual progression risk to cancer and requires treatment. The peptic stricture developed from chronic inflammation and fibrosis, explaining the dysphagia to solids.

### Treatment
- Endoscopic eradication therapy: radiofrequency ablation (RFA) for flat dysplasia combined with endoscopic mucosal resection (EMR) for the nodular component
- Stricture dilation at time of endoscopy
- Continued high-dose PPI therapy indefinitely
- Surveillance endoscopy every 3 months after treatment until eradication confirmed

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## 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

![Eosinophilic Esophagitis](case_02_image.jpg)
*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

---

## Case 3: Esophageal Adenocarcinoma

### Patient Presentation
**Demographics:** 68-year-old male

**Chief Complaint:** Progressive dysphagia and weight loss for 3 months

**History of Present Illness:** The patient reports difficulty swallowing that started with solid foods and has progressed to include liquids over the past 3 months. He has lost 25 pounds during this time. He reports dull chest discomfort and occasional pain radiating to his back. He has a long history of heartburn that he never formally treated.

**Past Medical History:** Hypertension, type 2 diabetes, obesity (previous BMI 35, now 29)

**Social History:** 40 pack-year smoking history (still smoking), moderate alcohol use

### Physical Examination
- **Vital Signs:** BP 132/82 mmHg, HR 84 bpm, BMI 29
- **General:** Cachectic male appearing older than stated age
- **Neck:** 2 cm firm, non-tender left supraclavicular lymph node (Virchow's node)
- **Abdomen:** Soft, no hepatomegaly

### Workup and Results
- **Upper Endoscopy:** Ulcerated, friable mass at 35 cm extending to the GE junction; unable to pass scope
- **Biopsies:** Invasive adenocarcinoma
- **CT Chest/Abdomen/Pelvis:** 5 cm esophageal mass with mediastinal lymphadenopathy; liver metastases
- **PET-CT:** FDG-avid primary tumor, mediastinal nodes, and hepatic lesions
- **FNA of Virchow's node:** Metastatic adenocarcinoma

![Esophageal Adenocarcinoma](case_03_image.jpg)
*Endoscopic image of esophageal adenocarcinoma showing an ulcerated, fungating mass arising in the distal esophagus at the gastroesophageal junction, causing near-complete luminal obstruction.*

**Image Source:** Case courtesy of Radiopaedia.org

### Diagnosis
**Stage IV Esophageal Adenocarcinoma**

### Clinical Correlation
Esophageal adenocarcinoma arises from Barrett's esophagus in the distal esophagus, driven by chronic GERD. Risk factors include obesity, GERD, Barrett's esophagus, smoking, and male sex. The progression of dysphagia from solids to liquids indicates worsening mechanical obstruction. Back pain suggests mediastinal invasion. Virchow's node (left supraclavicular) represents metastatic spread via the thoracic duct. Symptoms often present late because the esophagus can accommodate substantial tumor growth before causing obstruction.

### Treatment
- Given Stage IV disease: palliative intent
- Esophageal stent placement for dysphagia relief and nutrition maintenance
- Systemic chemotherapy (FOLFOX or fluoropyrimidine-based regimen)
- Immunotherapy if PD-L1 positive or MSI-high
- Radiation therapy for bleeding or local palliation
- Supportive care and nutrition optimization
- Overall 5-year survival <5% for metastatic disease