A 19-year-old male patient presents to your office with complaints of intermittent dysphagia and food impaction. The patient states that his symptoms have become progressively worse during the past two years. Two days ago, the patient got a piece of steak lodged in his esophagus while eating at a friend’s barbecue. The patient states that it took him more than an hour to dislodge the piece of meat from his esophagus; he accomplished this by self-induced vomiting. His vital signs were blood pressure, 127/82 mm Hg; heart rate, 82 beats per minute; respiratory rate, 18 breaths per minute; temperature, 98.6°F. His saturated oxygen on room air was 99%.
The endoscopy with biopsy, which is the procedure that should be ordered first, revealed suggestion of feline esophagus and a possible widely patent distal esophageal ring. Four biopsies were taken, and dilation was performed.
- Esophagus nonneoplastic, basal cell hyperplasia: absent, number and distribution of
- Eosinophils: highest number in one HPF 38; presence of neutrophils: absent
- Epithelial spongiosis (intracellular edema): present; diagnosis: esophageal squamous mucosa, consistent with eosinophilic esophagitis; evaluate for eosinophilia.
Based on the findings from the endoscopy and pathology report, the patient should be referred to allergy/immunology for further evaluation. The allergist will reveal the foods and/or the environmental allergens that are causing the reaction. The allergist will conduct radioallergosorbent and skin-prick tests. Once the patient knows what to avoid, medication will be prescribed to help manage his or her symptoms.
Treatment and management
When considering EoE, it is important to recognize that the therapeutic management of the disease includes pharmacologic, endoscopic, and dietary interventions.9 Exposure to food allergens plays a massive role in the pathogenesis of EoE; dietary approaches to treatment are numerous and include elemental diets and targeted elimination diets.1 Dietary modification has shown promise; patients placed on elemental diet therapy have had complete symptomatic and histologic resolution of EoE. Although effective, elemental diets have several disadvantages; elemental diets are often administered through a nasogastric tube, and if the diet is discontinued, the disease and symptoms usually return.3 Both elemental and elimination diet therapies have been shown to be effective in children.1,2 As a result, experts agree that dietary modification therapies are effective at controlling symptoms and eosinophilic infiltration in the esophagus.1
Treatment of EoE with medication continues to be the mainstay.1 Aerosolized corticosteroids that patients swallow remain the first-choice pharmacotherapy.1 The use of corticosteroid treatment in EoE is aimed at improving clinical symptoms and reversing inflammatory changes in the esophagus.10 Clinical experience suggests that response rates may increase with a higher dose of fluticasone. A 2013 guideline issued by the American College of Gastroenterology (ACG) suggested that the dose in children can range from 88 to 440 mcg/day in divided doses, while the dose in adults can range from 880 to 1,760 mcg/day in divided doses.9 The patient should be instructed to not inhale the drug but to swallow the aerosolized agent so that the drug may be delivered to the esophagus.9 Patients are instructed to swallow two puffs twice daily after meals.2 Patients should refrain from eating and drinking for 30 minutes after administration of the aerosolized agent.10
Corticosteroid treatment has been effective in about 70% of adult EoE patients2; however, if therapy is discontinued, it is common for patients to have symptomatic relapse.2 Research also supports the use of PPI therapy.2 The recent guidelines suggest that PPI use is a reasonable concomitant therapy when combined with corticosteroids.3 This may be due to recent research findings demonstrating a specific EoE phenotype that responds to PPI therapy.1 Furthermore, if a patient with esophageal dysfunction presents to the clinic, a trial of PPI therapy to rule out GERD would be a reasonable initial approach.3 Systemic corticosteroids have shown success in adult and pediatric patients, but adverse effects limit their long-term use.3