A 23-year-old man comes to the office due to problems with swallowing. For the past 2 years, the patient has had episodic sensations of food sticking in the chest associated with burning discomfort in the retrosternal area. The symptoms have become more frequent and severe and occur primarily when he eats meat or dry bread; the patient has no difficulty swallowing water, coffee, or protein shakes. He has attempted treatment with over-the-counter famotidine without improvement. A review of systems is negative for weight loss. Medical history includes intermittent asthma treated with an inhaled beta-agonist as needed. Vital signs are normal. Heart and lung sounds are unremarkable. The abdomen is soft, nontender, and nondistended. Which of the following is the most likely explanation for this patient's symptoms?
Eosinophilic esophagitis in adults | |
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Th2 = T-helper cell type 2. | |
Dysphagia (difficulty swallowing) is categorized as either oropharyngeal (difficulty initiating a swallow, with coughing/choking after eating) or esophageal (sensation of food stuck in the esophagus). Esophageal dysphagia to both solids and liquids indicates a motility disorder, with intermittent (eg, esophageal spasm) or progressive (eg, achalasia) symptoms depending on the underlying condition. Esophageal dysphagia to solids generally reflects mechanical obstruction; symptoms can also be intermittent or progressive (eg, from solids to liquids), which suggests a developing stricture or cancer.
Eosinophilic esophagitis (EoE) is characterized by extensive eosinophilic infiltration of the mucosa. It most commonly affects younger men (age 20-30) and is often associated with other atopic conditions (eg, asthma, eczema). It classically presents with intermittent solid-food dysphagia (often associated with eating meat) that can be described as food "sticking" in the chest. Other common manifestations include refractory gastroesophageal reflux (eg, retrosternal burning) and chest/upper abdominal pain. If not recognized early, EoE can progress to fibrosis, leading to esophageal strictures that result in progressive dysphagia and food impaction.
The endoscopic appearance of EoE includes furrowing; small, whitish exudates; and multiple stacked, ringlike esophageal indentations (trachealization of the esophagus). The diagnosis is confirmed with esophageal biopsy demonstrating ≥15 eosinophils/hpf. Management includes dietary therapy (eg, allergen avoidance, elimination diet), proton pump inhibitors, and topical glucocorticoids (eg, swallowed fluticasone spray, budesonide).
(Choice A) Achalasia results from the degeneration of myenteric plexuses in the esophagus, which prevents the lower esophageal sphincter from fully relaxing. Dysphagia is typically progressive, not intermittent, and involves both solids and liquids.
(Choice C) Esophageal cancer typically causes slowly progressive, not intermittent, dysphagia. In addition, it is typically associated with unintended weight loss and is rare in patients in their 20s.
(Choice D) Esophageal candidiasis can cause dysphagia and odynophagia but usually presents acutely to subacutely, not chronically over 2 years. It is often associated with oral thrush, and most patients have underlying immunosuppression (eg, systemic glucocorticoid therapy, uncontrolled diabetes mellitus).
(Choice E) Peptic stricture typically causes persistent and progressive, rather than intermittent, dysphagia. It usually occurs in patients with a long history of acid reflux symptoms and is uncommon in young adults.
Educational objective:
Eosinophilic esophagitis usually presents as intermittent solid food dysphagia and most commonly affects younger men with atopic conditions. Untreated disease can cause esophageal stricture and food impaction. Management includes dietary therapy (eg, allergen avoidance, elimination diet), proton pump inhibitors, and topical glucocorticoids (eg, fluticasone, budesonide).