Outpatient Case Presentation Dean Keller, M.D. GIM Conference 3-12-2008

Objectives To present a “newer” disease entity through a case presentation and review of the literature No financial disclosure

Eosinophilic Esophagitis-Essentials of diagnosis Clinical symptoms of esophageal dysfunction Esophageal mucosal biopsy containing greater than 15 intraepithelial eosinophils per HPF Lack of response to PPI

Symptoms and Signs Most common is intermittent dysphagia and food impaction in young adults Esophageal stricture Nausea, vomiting, regurgitation Heartburn Absence of red flags

Lab and Endoscopic Findings Mild peripheral eosinophilia in 5-50% Dense eosinophilic infiltrates on esophageal biopsy of squamous epithelium Endoscopic features linear furrowing, circular rings, strictures, crepe paper mucosa, white exudates Stricture: proximal, middle, or distal

Treatment Newer disease entity-most evidence is grade c (clinical experience, descriptive studies, reports of experts committees) Dilation of strictures-longitudinal tears but no perforation-good response Fluticasone 220mcg 4 puffs swallowed daily for 6 weeks Elimination diets not helpful in adults

Follow up and Prognosis Maintenance treatment has not been studied Repeat endoscopy based on recurrent symptoms 7.2 years of f/u on 30 adults 11/30 required dilation No increase risk of malignancy or Barrett’s changes over 11 year f/u period

References Yan BM, Shaffer EA. Eosinophilic esophagitis: A newly established cause of dysphagia. World J Gastroenterol 2006;12(15):2328-2334. Furuta GT, Liacouras CA, Collins MH, et al. Eosinophilic esophagitis in children and adults: A systematic review and consensus recommendations for diagnosis and treatment. Gastroenterology 2007;133:1342-1363.