in interesting case of dysphagia which turned out to be eosinophilic esophagitis

1. Rare case of dysphagia !!!
By : Dr Shaz Pamangadan
Chair : Prof. Balakrishnan Valliyot

2. 28/M.
Kannur
Working field staff in insurance company .
Presenting complaints :
Dysphagia of solid foods – since 3 months
Nausea and substernal discomfort – 10 days

3. History of presenting complaints :
Complains of difficulty swallowing which is intermittent , non-
progressive , worse with solids most commonly after lunch …
food get stuck in the base of throat  emesis, with relief of
obstruction
Also c/o occasional sub-sternal discomfort .
No pain on swallowing, no heartburn, no wt. loss , no change in
bowel habits , fever abdominal pain , diarrhoea , constipation .
No difficulty swallowing liquids .
Only slight improvement with Esomoprazole . Stopped due to
nausea.
Referred to GE

4. Past History:
Allergic rhinitis as a child, treated with
immunotherapy. Mild symptoms presently except
around pets.
Otherwise healthy : no cardiac disease, rashes,
arthritis, fevers, chills, diarrhea, travel.
No GI disease .

5. • Family history :
No family h/o cancer or similar illness .
• Personal history :
Non smoker , no addictions .
Mixed diet
Sleep , appetite normal

6. Examination
• BP – 128/78
• PR-82/mt regular
• RR-14/mt
• T-Afebrile
• No PICCLE

7. Systemic Examination
• GIT – P/A soft ; No HSM ; bowel sounds heard ;
oral cavity - wnl
• CNS- conscious ; oriented ; No FND
• RS- NVBS b/l ; no added sounds
• CVS : S1S2 N ; no murmur.

8. CBC
• Tc – 6000
• N-65 ; L 42 : M 00 : E 08
• ESR – 16
• PLT -218
• Hb -12.6
• LFT, RFT , SE , URE , CXR - wnl
• ECG ,TSH , FT4 - wnl
• Usg abd+kub - WNL

9. • Differential diagnosis:
– Peptic stricture (from reflux esophagitis).
– Motility disorder (eg achalasia, esophageal spasm)
Hypertensive lower esophageal sphincter
– Schatzki ring ; webs and rings
Zenker's diverticulum
Esophageal varices ; Esophagial diverticula
Scleroderma
Esophageal cancer ; Eosinophilic esophagitis
Hiatus hernia, especially paraesophageal type
Dysphagia lusoria ; Gastroesophageal reflux

10. Further Work up :
Barium swallow: narrowing of distal esophagus.
Endoscopy showed :
“Ringed” esophagus
Several “polypoid/nodular” areas biopsied
Narrowing of the distal esophagus
Whitish exudates , vertical furrows present.
Not consistent with Schatzki ring
Stricture  dilated …

11. Ringed Esophagus

12. Esophageal nodules

13. Whitish exudates

14. Biopsy Results
Esophagus:
Moderate chronic inflammation .
Squamous mucosa with marked infilteration of
eosinophils in subepithelium (85/HPF)
No dysplasia

15. • Serum IgE level 987 IU/ml (150-1000)

16. Diagnosis ??
• Adult eosinophilic esophagitis

17. Allergy Consultation
Dysphagia of solids persists occasionally , but no
further vomiting episodes since esophageal
dilatation.
No history of food allergy, but on careful
questioning reports slight itchy throat to peanuts,
eggs, possibly nuts.

18. Skin Testing-scratch
Food Wheal/flare Food Wheal/flare
Egg 10/45 Malt 5/12
Peanut 7/20 Wheat 3/5
Fish Mix 6/30 Beef 0
Hazelnut 10/30 Chicken 0
Almond 4/8 Milk 0
Other nuts 0 Soy 0
Pork 4/12 Shellfish mix 0
Lamb 5/15

19. Food avoidance for 1 month:
 all positive skin tests .
Pulse steroid + supportive treatment given.

20. Follow Up
Marked Improvement of symptoms …
Still with some dysphagia but no choking or
vomiting (since dilatation)
Avoiding egg, pork, lamb, fish, malt, peanuts, and
nuts…

21. ADULT EOSINOPHILC ESOPHAGITIS

22. Prevalence ??
• Atopic male (male/female ratio 2:1 to 3:1)
presents in childhood or during the third or
fourth decades of life
• White, non-Hispanic.
• Prevalence is increasing with rate 6-30
cases/100,000
• EoE in the United States 52/100,000

23. Definition
• • A chronic, immune/ antigen-mediated
esophageal disease characterized clinically by
• symptoms related to esophageal dysfunction
• histologically by eosinophil-predominant
inflammation

24. Pathophysiology ??
food allergy ? …. h/o allergy ??? Background
h/o allergy ??

25. Diagnosis
• 1. Symptoms related to esophageal
dysfunction
• 2. One or more esophageal biopsy specimens
show >15 Eo/hpf (peak value)
(minimum threshold for a diagnosis of EoE)
• 3. Disease is isolated to the esophagus (other
causes of esophageal eosinophilia should be
excluded )
• 4. Disease remit with treatments of dietary
exclusion, topical corticosteroids, or both .

26. Clinical Manifestration
• • Adult : Steriotypical symptom - Dysphagia
- Chest pain
- Food impaction
• - Upper abdominal pain
• Any pt with symptom suggestive of EoE should
undergo careful history focus on eating and
swallowing habits .

27. Endoscopic Finding
• Fixed esophageal rings (corrugated rings or
trachealization) or Transient esophageal rings
(feline folds or felinization),
• Can be predictive…
• • Whitish exudates ; Longitudinal furrows
• pathognomonic for EoE
• Edema & Diffuse esophageal narrowing
• Narrow-caliber esophagus
• Esophageal lacerations by passage of the
endoscope

28. Histologic Finding
• At least 15 Eo/HPF in the maximally affected
esophageal tissue
• Esophageal pH monitoring (and pH
impedance ) useful diagnostic test to evaluate
for GERD in patients with esophageal
eosinophilia
• Peripheral eosinophil counts: patients EoE,
40% to 50% having increased numbers of
circulating eosinophils (>300-350 per mm3)
• Total IgE : may or maynot be elevated .

29. Allergic evaluation
• • EoE is an antigen-driven allergic condition
• • EoE patient
• - 28% to 86% of adults
• - 42% to 93% of pediatric
• • 50% to 60% of patients with EoE have a prior
history of atopy
• • Major of patients have sensitization to food
allergens, aeroallergens, or both (SPT or
Specific IgE )

30. Treatment
• Diet therapy
• • Elemental diet : complete elimination of
dietary antigen and use amino acid formula
• Elimination diet
• • elimination of certain food allergens
• Restrict most common food allergens VS
• Restrict proteins based on allergy testing

31. • Phamacological
• • Oral corticosteroid
• - improve esophageal eosinophilia and
symptoms in patients with EoE
• - disease relapse within less than 6 months
after cessation & adverse effects of long-term
treatment
• - used in severe cases,recommended dose 1-2
mg/kg of prednisone equivalent

32. • Thank you