Eosinophilic Esophagitis: An Overlooked Entity in Chronic Dysphagia

Brian M. Yan and Eldon A. Shaffer

Disclosures

Nat Clin Pract Gastroenterol Hepatol. 2006;3(5):285-289. 

In This Article

The Case

A 40-year-old white male presented to our gastroenterology division in March 2004 with a 10-year history of occasional heartburn two to three times per week, with mild solid-food DYSPHAGIA, occurring several times per week. The patient had most difficulty swallowing carrots, meat, and rice, but eventually they would pass on their own, usually without ingesting fluids. Food impaction never occurred. There was no history of nausea, vomiting, or hematemesis. He had no constitutional features such as weight loss, fever, or night sweats to suggest a systemic disease, and no prior history of ingestion of lye or other noxious agents. Medications included salbutamol (for mild asthma) and occasional ranitidine (for mild heartburn), both taken on an on-demand basis. A SCHATZKI'S RING was identified at elective endoscopy performed at a different center to investigate his intermittent dysphagia 8 years before the patient's most recent presentation. Treatment with dilatation was effective in improving symptoms until about 2 years ago, when they recurred.

The patient also had a significant history for atopy, including allergic conjunctivitis, chronic rhinosinusitis, chronic idiopathic urticaria, and mild asthma. His allergic history extended to tree nuts, fish, environmental factors, and pets. The patient's family history was also positive for asthma and atopic dermatitis in both parents. His physical examination was within normal limits.

Laboratory investigations revealed a slightly elevated eosinophil count of 0.9 × 109/l (normal range 0.0-0.7 × 109/l); hemoglobin concentrations, red and white blood cell counts, electrolytes, creatinine levels, liver function tests, and thyroid function were normal. Allergy skin testing was positive for tree nuts, fish, dogs, cats, rabbits, horses, dust mites, birch trees, and grass. Video esophagram was normal. Upper endoscopy revealed the presence of concentric, corrugated rings along the entire length of the esophagus resembling a 'feline' esophagus (Figure 1). Mid-esophageal and distal-esophageal biopsies showed a dense superficial eosinophilic infiltrate (>20 eosinophils per high-powered field [HPF], Figure 2).

Figure 1.

Upper endoscopy image of a 40-year-old male presenting with a history of chronic heartburn and solid-food dysphagia, showing coarse concentric rings throughout the entire length of the esophagus (resembling the feline esophagus), suggesting eosinophilic esophagitis. This figure also demonstrates a diffusely narrowed esophagus, mild linear furrows, and adherent papules. Biopsies of the distal-esophagus and mid-esophagus confirmed eosinophilic esophagitis.

Figure 2.

Proximal esophageal biopsies of a 40-year-old male with eosinophilic esophagitis. (A) Low-powered field showing inflammatory infiltrate of the esophageal mucosa. Aggregates of eosinophils are readily seen (arrows). (B) High-powered field showing >20 eosinophils and aggregates of eosinophils (arrow).

The patient was diagnosed with eosinophilic esophagitis and treated with a fluticasone 220 µg multiple-dose inhaler, four puffs swallowed twice a day for 6 weeks. His dysphagia completely resolved after treatment and he remains in remission at 6-month follow-up.

Comments

3090D553-9492-4563-8681-AD288FA52ACE
Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.
Post as:

processing....