Contribution by: dr. H. Uchima University Hospital Clinic Barcelona “How to approach a patient with eosinophilic esophagitis and a long Barrett segment containing HGD”

Case (I) A 42 year old man with a past medical history of allergic rhinitis presents with an episode of dysphagia with esophageal food impaction that required upper endoscopy for extraction. Medication: antihistaminics, PPI Intoxications: -

Endoscopy June 2013 showing food impaction

Case (II) The biopsies showed: A week later an upper endoscopy was repeated showing: Linear furrows and mucosal fragility Hiatal hernia C9M11 Barrett’s esophagus, no visible lesions and no irregularities (FICE and acetic acid 2%) The biopsies showed: Squamous epithelium: oesophagitis with increased number of eosinophils Proximal in Barrett’s segment: intestinal metaplasia (IM) with low grade dysplasia (LGD) Distal and middle part Barrett’s segment: IM, no dysplasia

Case (III) The diagnosis eosinophilic esophagitis was made and the patient was treated with oral fluticasone for two months and was put on an exclusion diet after allergy testing. After the treatment the patient had no more dysphagia symptoms.

Case (IV) The biopsies showed the same as previously: Six months later an upper endoscopy was performed showing: No macroscopic signs of EoE Hiatal hernia C9M11 Barrett’s Oesophagus, no visible lesions and no irregularities (FICE and acetic acid 2%) The biopsies showed the same as previously: Squamous epithelium: oesophagitis with increased number of eosinophils In the proximal part of the Barrett’s segment IM with LGD

Case (IV) The latest showed: Linear furrows The known C9M11 Barrett’s oesophagus without any visual abnormalities (FICE and acetic acid 2%) However, this time the biopsies showed high grade dysplasia and persistent esophagitis with an increased number of eosinophils in the squamous epithelium.

Summary In summary, a patient with a long Barrett’s segment with high grade dysplasia and asymptomatic eosinophilic esophagitis after treatment with oral fluticasone and under adequate PPI.

Should this patient be treated with RFA or is eosinophilic esophagitis a contraindication for RFA treatment? What to do?

Advise It is important to know whether the patient has anstenosis (due to the eosinophilic oesophagitis). Because the esophagus in this case was not stenosed, there is no contra-indication for RFA and RFA treatment is considered the treatment of choice. However, special attention should be paid to careful sizing of the esophagus.