Eosinophilic Esophagitis

Case Presentation 35 year old man presented with intermittent upper esophageal dysphagia, mostly with solids for > 5 years. It had become progressively worse and he had problems swallowing “any solid food”. No weight loss. No heartburn symptoms. No prior treatment, no current meds

EGD Although no stricture was seen in the esophagus or the GE junction, moderate pressure was needed to advance to this point. Multiple rings were seen intermittently throughout the esophagus. The endoscopy could not be advanced beyond the GE junction –due to the floppy, tortuous esophagus.

9/26/2016Michael B. Harper, M.D.4 As the scope was withdrawn a 3cm superficial mucosal tear was seen in the mid esophagus.

9/26/2016Michael B. Harper, M.D.5

9/26/2016Michael B. Harper, M.D.6 There was no blood loss. Although the mucosa did not appear inflamed, it was friable and thin.

9/26/2016Michael B. Harper, M.D.7

Multiple cold forceps biopsies were taken from the GE junction and middle third of the esophagus –avoiding the site of the mucosal injury

9/26/2016Michael B. Harper, M.D.9 Impression Friable mucosa, with superficial linear tear. Eosinophilic esophigitis, Strongly suspected

9/26/2016Michael B. Harper, M.D.10 Plan Soft diet for 24 hours after EGD (due to mucosal injury) Start esomeprazole 40gm/d

9/26/2016Michael B. Harper, M.D.11 Pathology report Both biopsies display esophageal squamous mucosa with acute basal cell hyperplasia and increased eosinophilic inflammation with areas in excess of 30 eosinophils per high power field consistent with eosinophilic esophagitis. A PAS-D stain performed on the mid esophageal biopsy showed no evidence of fungal microorganisms.

9/26/2016Michael B. Harper, M.D.12 marked basal zone hyperplasia

9/26/2016Michael B. Harper, M.D.13 large numbers of eosinophils greater than 40 per high power field

9/26/2016Michael B. Harper, M.D.14 Plan following path report Started fluticasone 220ucg bid, do not inhale, and rinse mouth with small amount of water Changed to lansoprazole orally disintegrating tablet –dysphagia with capsule Consult allergist for food allergy testing and elimination diet

9/26/2016Michael B. Harper, M.D.15 Plan following path report Plan repeat EGD –After 6 weeks of treatment with pediatric endoscope –To confirm stomach and duodenum not involved TNE if further esophageal exams needed

9/26/2016Michael B. Harper, M.D.16 The mucosa may appear normal Multiple rings are a typical finding –Corrugation –"trachea-like" Teaching points with eosinophilic esophagitis

9/26/2016Michael B. Harper, M.D.17 linear furrowing ulceration and strictures multiple whitish papules or granular exudates Other finding seen with eosinophilic esophagitis

9/26/2016Michael B. Harper, M.D.18 Perforations are common do not force the endoscope avoid dilatation –or wait until after treatment Teaching points with eosinophilic esophagitis

9/26/2016Michael B. Harper, M.D.19 Diagnosis is based on clinical presentation and finding eosinophils on bx –Number per HPF not agreed upon –>15-25 is typically used Eosinophils can be caused by GERD –Best to biopsy after treatment with PPI for at least 4 weeks Teaching points with eosinophilic esophagitis