This document describes a case of a 28-year-old man presenting with dysphagia of solid foods for 3 months. Endoscopy and biopsy revealed eosinophilic esophagitis, with a marked infiltration of eosinophils in the esophagus and positive skin tests to several foods. He was placed on an elimination diet avoiding the foods he tested positive to, along with steroid treatment, which led to marked improvement in his symptoms. The document discusses the definition, pathogenesis, clinical manifestations, diagnostic criteria involving endoscopy and histology findings, allergy evaluation, and treatment options including dietary elimination and steroids for 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