A 10-year-old boy is brought to the emergency department due to difficulty swallowing. During dinner a few hours ago, a piece of chicken became stuck in the patient's mid-chest region. He has previously had the sensation of food becoming stuck, but it never lasted this long. The patient has vomited multiple times, but the chicken has not dislodged. Medical history is significant for eczema. He is drooling and visibly uncomfortable. Endoscopy is performed to remove the chicken from the esophagus and reveals multiple, vertically-stacked, ring-like indentations. Longitudinal crevices parallel to the length of the esophagus are also seen, along with scattered, small, whitish papules. Which of the following findings is most likely to be found on biopsy of this patient's esophagus?
Eosinophilic esophagitis | |
Pathogenesis |
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Epidemiology |
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Clinical features |
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Th2 = T helper 2. | |
This patient with a history of solid food dysphagia has an esophageal food impaction due to eosinophilic esophagitis (EOE). EOE is a chronic Th2 cell−mediated disorder triggered by food antigen exposure. When activated, Th2 cells release chemokines (eg, IL-13, IL-5) that stimulate eosinophilic recruitment to the esophageal mucosa.
EOE is most common in male individuals with a history of atopic conditions (eg, eczema, asthma). Patients often have intermittent solid food dysphagia. Other symptoms include vomiting, reflux, and chest and upper abdominal pain. When EOE is severe, food can become trapped in the esophagus (ie, food impaction), requiring endoscopy to remove the impacted food bolus.
Classic endoscopic findings include stacked, ring-like indentations with linear furrowing; and scattered, small, whitish papules (ie, eosinophilic microabscesses). Biopsies demonstrate eosinophilic mucosal infiltration.
(Choice B) Achalasia results from ganglionic degeneration within the esophageal myenteric plexus, leading to the inability to relax the lower esophageal sphincter. It typically causes dysphagia of both solids and liquids and is rare in children. There are no specific endoscopic findings; however, a barium swallow demonstrating a bird-beak appearance of the esophagus is characteristic.
(Choice C) Barrett esophagus is a premalignant condition characterized by intestinal metaplasia of the esophageal epithelium. It typically develops in older patients with chronic gastroesophageal reflux but does not usually cause food impaction.
(Choice D) Systemic sclerosis results in esophageal smooth muscle fibrosis, leading to severe gastroesophageal reflux. It occurs more commonly in adult women and usually presents with thickened skin and Raynaud phenomenon. Endoscopy typically demonstrates a dilated esophagus.
(Choice E) Herpes simplex virus esophagitis is characterized histologically by eosinophilic intranuclear inclusions within esophageal squamous cells. It typically occurs in immunocompromised patients and results in severe odynophagia. Endoscopy demonstrates ulcerations with a volcano-like appearance.
Educational objective:
Eosinophilic esophagitis is a Th2 cell−mediated disorder leading to eosinophilic infiltration of the esophageal mucosa. It occurs most commonly in male individuals with a history of atopic conditions and typically presents with solid food dysphagia, reflux, and occasionally food impaction. Classic endoscopic findings include stacked, ring-like indentations; linear furrowing; and scattered, small, whitish papules (ie, eosinophilic microabscesses).